Medicare Set-Aside & Medicare Recovery Programs

MRM offers an advanced program management platform to navigate its clients through the complexities of the Federal government’s Medicare Set-Asides, the Medicare Recovery Programs and their traditional payment lien letters. To address these major areas of concern, MRM retained and brought in house an attorney certified in Medicare Set-Aside consultations. He is only one of 17 certified in the State of Alabama. He runs and manages the entire Medicare Set-Aside program and the traditional payment lien programs for our clients.

For example, in order to close out your old medical files in pain management, you have to use a Medicare Set-Aside Agreement. The problem is that most of these old claimants are already on Medicare, so when you do your pharmaceutical or treatment Utilization Review on these pain management files, you might discover that a doctor is continuing to prescribe pharmaceuticals or treatment to an employee, notwithstanding that they have been blocked, and continuing to bill Medicare, which, in turn, is continuing to pay them. When you try to settle this employee’s medical benefits, you have to use the MSA Program, which is a standard program whereby you get value for that case through Medicare by buying an annuity to fund that buy out. Once annuitized, and settled through the court with the MSA is intact, Medicare will send a conditional payment lien letter requesting reimbursement for all the money they paid on behalf of that claim to the pain management doctor, whether it was pharmaceuticals or procedures. You will be financially responsible for all the unauthorized treatments if you do not file the proper objections within 30 days. Our staff attorney monitors and responds to all those conditional payment liens on behalf of our clients.

This is the most predominate area for concern for any self-insured account, trade association or any insurance carrier dealing with Medicare and the Federal government over the next five years. If you are not on top of the regulations and requirements and have not implemented cost containment program management, you could be required under the Medicare Recovery Act to go back to files that have been closed and be forced to reopen them and pay Medicare for all those treatments that you blocked or did not pay for, but that the doctors submitted to Medicare for payment. You will be financially responsible for all those payments that Medicare made plus penalties and fines. When your actuaries see this, they are going to increase your IBNRs (Incurred But Not Reported) and you could be bankrupted. It will be a domino effect, and the Federal government will enact a National Work Comp Act where all the benefits are now paid by the Federal government and there will no longer be any self-insured work comp. MRM can help you to prevent such a calamity, if you are proactive and implement our program management platform now.

MRM is the only TPA in the Southeastern United States that has a specialized staff attorney whose sole responsibility is to provide this program management platform. If you want to really protect yourself and implement advanced program management, we will take your old pain management files from 2004 and back and bring those files into a Medicare Set-Aside program, fund them with annuities, and get out 60 percent of the reserves. We will actually utilize the Medicare Set-Aside statutes as a partial loss portfolio transfer for our larger accounts. Now that is very advanced program management.

Medicare Set-Aside & Medicare Recovery Programs

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