1. Experience nationwide since 1986
  2. URAC certified since 1997
  3. 99.9% on-time for anywhere from 2-7 business days
Medicare Set-Aside Clinical Review (MSA-CR)
  • Purpose: Estimate the clinical component of an injured worker’s Medicare Set-Aside settlement so the MSA facilitator can reach agreement with:
    • CMS
    • Plaintiff (injured worker)
    • Plaintiff Attorney
    • Payer
    • Defense (for Payer) Attorney
    • Treatment provider(s)
While MSA’s typically just extrapolate current care over the injured worker’s potential lifetime, this review will project what changes can be made immediately and over the long-term to best fit the injured worker’s circumstances to allow a return to work and health.
  • Triggers:
    • Settlement is desired
    • Future medical costs to exceed $5000/year
    • Lifetime medical treatment is expected
    • Causal relationship issues to WC persist
    • Co-morbidity conditions effect treatment
  • Scope:
    • Plan of care (procedures and treatment present and anticipated)
    • Medical necessity
    • Reasonableness
    • Causal relatedness
    • Pain management regimen (present and anticipated)
  • Reviewer: Active practice MD
  • Inputs:
    • Current settlement assumptions and calculations
    • Medical records (no limit)
    • RX scripts and bills
    • Other reviews like DUR or IME or peer reviews
    • Peer-to-peer discussion
    • Evidence Based Medicine
    • Reviewer’s active clinical and academic experience
    • Latest medical research
  • Discussion: Unless otherwise stipulated by the customer, all treatment provider(s) will be contacted
  • Option: Unless otherwise stipulated by the customer, PRIUM will attempt to get the treatment provider(s) to agree in writing to any recommended modifications
  • QUOTE (something like a note in a shadow box): “A recent MSA-CR created savings of $183,675 from the originally planned MSA settlement (and was accepted by the CMS and agreed-upon by the Treatment Provider and Claimant)”