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)”
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