Medicare Setaside problems

[lucky]

(04-23-2012 08:06 PM)1171 Wrote:  yes in this respect a doctor is like any other business and is free to choose what payments they will accept.

PS. I don't think most set asides specify the work comp fee schedule.
you should look into changing the terms as it obviously reduces your choices and is little better then keeping your claim with the comp carrier and actually offers less protection then an open ended medical award.

I wonder how the comp schedule compares to medicare's?--once the set aside is exhausted you't be left with medicare only coverage.

Most Medicare Setasides per my Attorney use the Workers Comp fee schedule when a life care plan is built for a Medicare Setaside.

Everyone I know who has a MSA settlement is based on WC Fee schedule.
There is no changing as this is a C&R settlement.

In Louisiana,settling with open medical will not happen. I asked for this and the IC would not have it. The IC wants the IW released totally. NOW, some states have open medical as the option... Also I would prefer to not have WC in my life anymore and they would be with open medical.

I have friends in Illinois and Florida who settled with a C&R like me with a Medicare setaside and both are built around there states WC fee schedule. It is common to do this.

Medicare pays less; I know this by looking at the Diagnostic code which is the same code for WC and Medicare and also private insurance. This is a universal diagnostic code.

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This is from CMS website.

Use of WC Fee Schedule vs. Actual Charges for WC Medicare Set-aside Arrangement
(Ref: 10/15/04 Memo Q1)

The CMS uses either the WC fee schedule (for states that have such schedules) or the full actual charges for its review of a proposed WCMSA based upon whichever methodology is used by the individual/entity submitting the proposal. The administrator of the WCMSA (both professional administrators and self administrators) should make payments from the WCMSA on the same basis. That is, if the proposal was submitted and approved based upon full actual charges, the administrator should make payment from the WCMSA based upon full actual charges; if the proposal was submitted and approved based upon WC fee schedule amounts, the administrator should make payment from the WCMSA based upon WC fee schedule amounts.

The CMS reviews WCMSAs on a case by-case basis in order to determine whether Medicare has an obligation for services provided after the settlement that originally were the responsibility of WC. Accordingly, in reviewing a WCMSA, CMS must know whether the arrangement is based upon WC fee schedule amounts or full actual charge amounts. (Ref: 7/23/01 Memo Q5 Note).