Medicare Set-Aside Solutions
Los Angeles, CA
One
of our customers requested a MSA with a Center for Medicare and Medicaid Services
(CMS) Approval be completed on an Automobile Bodily Injury Liability
Claim that was being prepared for a final settlement. The plaintiff was
an 18 year old female who was a driver in a 2001 Subaru Legacy automobile
who entered an intersection with the light. The insured vehicle, GW
Bakery, Inc. truck entered the intersection against the light at an
excessive speed. A violent collision occurred ejecting the plaintiff
through the driver’s side window of the Subaru Legacy. The
plaintiff suffered severe vertebral fracture that required spinal surgery
along with a torn right knee meniscus that also resulted in surgery.
Other subsequent injuries of the plaintiff included bumps and bruises to
the plaintiff’s face, arms, and legs. The plaintiff recovered from
the surgeries but was unable to return to any gainful employment due to
continued residual pain in both her spine and the right knee along with
an overlay of psychological issues related to the incident. Prior to the
incident, the plaintiff was healthy with no significant medical or
psychological conditions present in the medical records history. The
customer requested a MSA with CMS Approval, along with a Structured
Settlement. The claim settlement
amount was approximately $1,287,000. Our MSA team was able to secure an
allocation of $575,000 which represented the additional expected medical
treatment for 62.9 years of the plaintiff’s remaining life
expectancy. CMS approved our
MSA Set-Aside allocation for only $560,000. A Structured Settlement was
put in place along with a Custodial Account to further enhance the cash
flow for our client. The customer was very pleased with the result,
and thanks to our dedicated work the claim settled very quickly between
the parties.
Greensboro, NC
In September
of 2009, one of our customers requested a MSA with a Center for Medicare
approval be completed on a Workers Compensation claim. The parties
settled the claim for $225,000, plus defendants funding of a
self-administered Medicare Set Aside at a cost to defendant not to exceed
$44,000. Our Client advised if the cost of the MSA was in excess of
$44,000, either party could void the agreement or they could negotiate
further.
This
case involved an established claim for an injury to the lumbar spine. Our
Analysts immediately removed all of the co-morbidities and found that the
claimant had a positive medical history for hypertension and excessive
cholesterol. The claimant suffered from prostate cancer in 2005 and was
treated with a radical prostatectomy. The incident occurred on or about
June 20, 2008. While working for the employer, the claimant alleged that
he sustained a compensable injury to his back by accident or specific
traumatic incident when he was attempting to move a heavy HVAC unit from
inside a large pickup truck bed to the tailgate of the vehicle. The
insured had accepted compensability for the incident of the
claimant’s low back claim. The claimant had been examined,
evaluated, diagnosed, and treated by a number of authorized doctors
including three orthopedists and by one physiatrist and a pain management
doctor. None of the orthopedics recommended surgery.
We
had an MSA completed for our client. Based upon the claimant’s
current medical status to date and frequency of treatment a projected
medical need of $41,256.25 was determined. We subsequently conducted a
Lien search and found no benefits were paid to the claimant. We submitted
our MSA to CMS for approval which we were able to secure for our client
within 35-40 days! CMS established the prescription benefits set aside based upon
“as needed” use of the medication which significantly lowered
the Part D Set Aside. CMS approved our MSA Set Aside allocation for only
$20,725.00. This resulted in an immediate earnings surplus gain of
$20,531.25 which went straight to the client’s bottom line. The
client was overjoyed and recognized the result as an extremely high
quality outcome. The response from the client is that “you will get
all my MSA’s and I will spread the word to all my colleagues so that
they know what a great job you all do.”
Baltimore, MD
During
the fall of 2009, one of our customers requested a MSA Allocation Report
be completed on a Workers Compensation claim. The parties settled the
claim for $24,500, plus the funding of a self-administered Medicare Set
Aside at a cost to defendant not to exceed $7,500.
Our
analyst began working on the referral, and immediately removed all of the
co-morbidities including coronary artery disease, status post
angioplasty, hypertension and irregular heartbeat. The incident occurred
on May 25, 2008. While working for the employer, the claimant alleged he
twisted his right wrist in a golf cart steering wheel when the golf cart
moved forward and hit a curb. The employer accepted the incident as a compensable
accidental injury to the right wrist. The claimant had been examined,
evaluated, diagnosed, and treated by two orthopedists and one pain
management doctor. Initial x-rays were taken showing a non-displaced
fracture of the right distal radius. The claimant was then placed in a
short arm cast and it was removed on follow-up due to discomfort in the
cast and continued pain. After several different doctor visits, the
claimant had surgery and was subsequently treated in a conservative
manner. Based upon the medical treatment, the claimant reached maximum
medical improvement in August, 2009. Our MSA Allocation Report provided
for 5 follow-up visits with the claimant’s treating orthopedic
surgeon with a provision for 12 visits of physical therapy and 12 visits
of occupational therapy over the next year. Our Set Aside also
recommended the cost of medications for 12 months. The lien search found
no benefits were paid to the claimant.
Based
upon the claimant’s current medical status to date and frequency of
treatment a total projected medical set-aside of $2,488.59 was
recommended. Since the Set Aside
was reserved for $7,500, the final result allowed for a reserve reduction
and an immediate earnings gain of $5,011.41. The client was extremely
pleased as the surplus savings of the MSA allocation we did assisted in
reducing the client’s reserves immediately and moving the case to a
very quick settlement and closure. The client responded with a resounding
“Great job and thank you.”
Baltimore, MD
Our client requested that our team conduct a medical records and bills reviewed for the reasonableness,
necessity, and causal relationship of the bills. Primarily, it appeared
that the claimant obtained treatment for personal medical conditions, but
was trying to relate the treatment to the client’s accident.
Out of $70,000 in medical bills being submitted, it appeared that many of
the bills were for unrelated conditions. The client had a workers
compensation hearing that was scheduled within two weeks of this request.
Our team put together an effective report that was delivered back to the
client as a rush request well before the hearing. The result was that out of $70,000 in medical bills reviewed only
$36,000 was found causally related to the original claim. The goal of
the Medical Causality Records Review was to determine which bills were
and were not causally related to the date of injury. The
client’s response to our work was, “Excellent report, thank you, and I will get this to the
adjuster for immediate payment.”
Albany, NY
In September of 2005, we were acting as risk
and executive general adjusting managers to mitigate costs for an
international aviation company who was serving international clients from
its fixed base operation at Albany
International Airport. One particular
worker’s compensation claim was having an extremely difficult time
in moving towards a settlement resolution. It involved an Equipment
Mechanic who was injured on 09/19/05 while unloading a potable water
cabinet from a company service truck. The Claimant allegedly slipped and
fell while lifting the water cabinet injuring his Lumbar Back and Coccyx
area. The Claimant was on Temporary Total Disability since the date of
injury, and remained in this status since the Customer unable to
accommodate any light duty work restrictions. The Claimant was 49 years
old at the time of the accident. The Workers Compensation Board
eventually classified the Claimant at $400 week Permanent Partial
Disability with symptomatic medical conditions treated with pharmacological
interventions. It was our immediate recommendation to replace the current
assigned Defense Counsel, and employ counsel who would seek a final
settlement. It was clear to us that the case would have cost another 25
years of lifetime benefits, or over $520,000. We were engaged with the
new Defense Counsel to secure a Section 32 full and final settlement. The
negotiations started with a $220,000 demand, which ultimately was reduced
to $150,000. At this point, we recommended that the Customer have a Medicare
Set-Aside (MSA) completed by us to lessen the value further. We then had
a MSA completed with Centers for Medicare and Medicaid Service (CMS)
Approval. The Claimant was found
to be Medicare eligible, which amounted to $10,000 for future Medical Set
Aside. With the MSA, the final settlement amounted to $140,000. This was
a savings of $80,000 off the original demand and a savings of $380,000 of
potential future PPD lifetime benefits that would have been paid if the
claim never settled. Additionally, in our role as outsourced risk
managers, we were able to successfully create safety standards, controls,
and training which allowed our client to continue their business at the
airport. The customer was extremely pleased with our aggressive approach
to cost compress all medical and indemnity exposures which helped to
reduce the client’s claims costs and frequency.
Pittsburgh, PA
During
the fall of 2007, one of our customers requested a MSA with a Center for
Medicare and Medicaid Services (CMS) Approval be completed on a Workers
Compensation claim that was ready for settlement. They requested the
lowest MSA Set Aside possible. The customer’s employee was injured
while employed as a painter. On November 28, 2005, Mr. Brown, a 62 year
old, was helping an associate lift a very heavy compressor. As he was
lifting his end he lost his balance, and in trying to keep from falling
he twisted and strained his lower back with L4-L5 Disc herniation. He was
treated with physical therapy and medications, and his condition
improved. The patient was offered surgery but he declined since his
condition was stable and improving. On July 30. 2007, Mr. Brown visited
the Insurance Company’s Independent Medical Examination (IME)
Orthopedic physician. Mr. Brown stated at the examination that he was
about the same as when he was first injured, and that he was able to
perform all his desired activities. The IME stated that the patient had
reached Maximum Medical Improvement. The physician’s
recommendations were to follow up with a surgeon, but Mr. Brown declined
and no further treatment was necessary. Additionally, Mr. Brown was a
Medicare beneficiary at the time. The medical records indicated that Mr.
Brown had no significant related co-morbidities, so there were no
conditions that either caused or aggravated Mr. Brown’s
work-related injuries. Therefore, we were not required to take any other
medical issues into consideration when approaching the MSA Zero
Allocation. The CMS Approval was
received for our Zero Allocation recommendation, which resulted in a
final $28,000 settlement. Customers rely upon us for our expertise
and experience to obtain the lowest possible MSA allocation amount for
these types of cases. In this particular case, we believe we saved our
client several hundred thousand dollars of workers compensation costs by
obtaining the desired result.
Syracuse, NY
In
January of 2008, one of our customers requested an MSA with a Center for
Medicare and Medicaid Services (CMS) Approval be completed on a Workers Compensation
claim that was being prepared for a final settlement, and requested the
lowest possible MSA arrangement. The employee was 66 years of age at the
time and a Medicare recipient. His injury occurred when as a Loan Officer
at a Bank he slipped and fell on ice in the customer’s owned and
maintained premises. The employee had hyper-extended his left knee which
resulted in a torn Meniscus. The employee had been having on-going
degenerative pain in the knee for years. The injury resulted in two
surgical repairs of the torn meniscus due to scar tissue build up after
the initial surgery. Eventually the employee recovered from the surgeries
and then retired from the company. However, he continued to have ongoing
chronic pain in the left knee that required pain medications due to his
preexisting degenerative conditions in the knee. The customer requested
an MSA with CMS Approval for settlement purposes. The claim settlement amount was approximately $50,000. Our MSA
team was able to secure an allocation of $5,800 which represented the
additional expected medical treatment for 16.1 years of the
employee’s remaining life expectancy. Our customer was very
pleased with the outcome, and thanks to our dedicated work the claim
settled very quickly with the employee’s attorney and Workers
Compensation Board.
Albany, New York
In
February 2008, one of one of our customers requested a MSA with a Center
for Medicare and Medicaid Services (CMS) Approval be completed on a
Workers Compensation claim that was being prepared for a final
settlement, and requested the lowest possible MSA Set Aside arrangement.
The employee was 40 years of age at time and on SSDI. The bank teller
claimant alleged an occupational claim of Bilateral Carpal Tunnel
Syndrome. The claim was found to be causally related by the New York
State Workers Compensation Board. The claimant ultimately had surgeries,
and recovered from them with only symptomatic pharmacy and doctor
appointments three to four times a year. The customer requested an MSA
with CMS Approval for settlement purposes. The claim settlement amount was approximately $50,000. Our MSA
team was able to secure an allocation of $4,500 which represented the
additional expected medical treatment for 42 years of the
employee’s remaining life expectancy. Our customer was very
pleased with the outcome, and thanks to our dedicated work the claim
settled very quickly with the employee’s attorney and Workers
Compensation Board.
New York, New York Workers Compensation Case Management
In November
of 2008, we were contacted to assist with case management monitoring of a
claim for one of our Customer’s who was having difficulty moving
towards a settlement resolution. The claim involved a Maintenance Service
worker who was injured on 03/08/06 while unloading carpets from a company
service truck. The Claimant allegedly slipped and fell injuring his
Lumbar Back and Coccyx area. The Claimant was on Temporary Total
Disability since the date of injury, and remained in this status since
the Customer unable to accommodate any light duty work restrictions. The
Claimant was 48 years old at the time of the accident. The Workers
Compensation Board eventually classified the Claimant at $400 week
Permanent Partial Disability with symptomatic medical conditions treated
with pharmacological interventions. It was our immediate recommendation
to replace the current assigned Defense Counsel, and employ counsel who
would seek a final settlement. It was clear to us and our Customer that
the case would have cost another 30 years of lifetime benefits, or over
$624,000. We were engaged with the new Defense Counsel to secure a
Section 32 full and final settlement. The negotiations started with a
$200,000 demand, which ultimately was reduced to $165,000. At this point,
we recommended that the Customer have a Medicare Set-Aside (MSA)
completed by us to lessen the value further. We then had a MSA completed
with Centers for Medicare and Medicaid Service (CMS) Approval. The Claimant was found to be Medicare
eligible, which amounted to $12,000 for future Medical Set Aside. With
the MSA, the final settlement amounted to $147,000. This was a savings of
$53,000 off the original demand and a savings of $477,000 of potential
future PPD lifetime benefits that would have been paid if the claim never
settled. Our Customer was very pleased, and uses us for all cases
where there are significant medical and indemnity matters.
Blackburn Group, Inc.
23 Bremen Circle, Penfield, NY 14526
(585) 586-4530, Email: sales@blackburngroup.com
RiskPro is a registered trademark of
Blackburn Group, Inc.
Copyright 1991-2010 Blackburn Group, Inc. All rights
reserved.