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When Treatment Costs Exceed Settlements
A message from Debra Forsythe, EPIQ | September 2025Navigating the complex landscape of lien resolutions in mass torts is a challenge for both plaintiffs' and defense attorneys. One of the biggest hurdles is complying with federal and state regulations to resolve health care liens while making sure injured claimants receive as much of their settlement as possible, an outcome to all parties' benefit once a settlement or judgment has been reached.... READ MORE How Plaintiff and Defense Attorneys Can Protect Beneficiaries' Finances and Health Care in MMSEA Section 111 Reporting Insufficient collaboration between plaintiff and defense attorneys regarding Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 reporting requirements creates administrative complications which can negatively impact beneficiaries’ finances and their health care treatment.... READ MORE Federal Court Grants Motion for Injunctive Relief, Finding that the Private Cause of Action Cannot be Used Against Beneficiaries The Medicare Secondary Payer Act (codified under 42 U.S.C. § 1395y(b)) provides two distinct causes of action for recovery of unpaid Medicare conditional payment debts... READ MORE Recap of NGHP Section 111 Reporting CMS Webinar on Civil Monetary Penalties CMS hosted a live webinar on January 18th at 1pm EST. This webinar provided valuable information for responsible reporting entities (RREs) as the industry prepares for CMS to begin quarterly compliance audits and the imposition of civil monetary penalties. READ MORE ALERT: Medicare Secondary Payer and Civil Monetary Penalties: Notice of Final Rule CMS has finalized what will arguably be the most significant rulemaking the Medicare Secondary Payer industry has ever had. The final rule specifies how and when Group Health Plan and Non-Group Health Plan reporting entities will be penalized civilly for failure to comply with Section 111 reporting requirements. A high-level outline of the highlights of this rule as it applies to Non-Group Health Plans (NGHPs) and the impact to the Responsible Reporting Entity (RRE) community can be found below. READ MORE The Needle is Moving on MSPN's Strategic Objectives CMS Releases Version 3.9 of the WCMSA Reference Guide
Published as Corporate Partner Benefit | May 2023
The Centers for Medicare and Medicaid Services (CMS) released version 3.9 of their Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide with a few modifications and additions, which are addressed in this article. READ MORE. Final Rule on CMPs ExtendedPublished as Corporate Partner Benefit | March 2023
The Final Rule outlining Centers for Medicare & Medicaid Services (CMS)’ guidance around Civil Monetary Penalties (CMPs) of up to $1000 per day/per claim —which may be issued against Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) for noncompliant MMSEA Section 111 reporting—has been delayed for an additional year, with a newly anticipated release date of February 18, 2024. READ MORE. Be a Part of Who We Are and What We DoA message from MSPN President John Kane | March 2023
When people ask about MSPN, I advise we are a national Medicare Secondary Payer (MSP) network made up of experts in the field. We have come a long way since 2005 when this organization was founded, and we continue to push forward our
mission and vision. Ametros White Paper: A Study of CMS Policy on Treatment Denials for Injured Workers with a Medicare Set Aside
Published as Corporate Partner Benefit | March 2022Produced with data from researchers at ResDAC, Ametros offers the first study of its kind analyzing quantitatively how often The Centers for Medicare and Medicaid Services (CMS) denies coverage for otherwise Medicare-covered items
for individuals after settlement of an insurance claim that involves medical liability. These denials impact individuals that have settled a workers’ compensation claim with approved Workers’ Compensation Medicare Set Asides (WCMSAs). Ametros White Paper: A Study of CMS Policy on Treatment Denials for Injured Workers with a Medicare Set Aside
Published as Corporate Partner Benefit | March 2022Produced with data from researchers at ResDAC, Ametros offers the first study of its kind analyzing quantitatively how often The Centers for Medicare and Medicaid Services (CMS) denies coverage for otherwise Medicare-covered items
for individuals after settlement of an insurance claim that involves medical liability. These denials impact individuals that have settled a workers’ compensation claim with approved Workers’ Compensation Medicare Set Asides (WCMSAs). CMS Released version 3.4: WCMSA Reference Guide UpdatedNahla D. Rizkallah, PharmD, MSCC, Senior Clinical Pharmacist, ExamWorks Compliance Solutions CMS Released Version 3.4 of the Worker's Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide on October 4, 2021. The revised changes highlights the need to provide CMS with final executed WC settlement contracts that include the WCMSA funding information in order for the CMS approval of the WCMSA to be effective. The revised Guide also changed all references from MyMedicare.gov to Medicare.gov. Opioid Red Flags
Nahla D. Rizkallah, PharmD, MSCC, Senior Clinical Pharmacist, ExamWorks Compliance Solutions The opioid epidemic continues to be a public health emergency, with 136 deaths per day and climbing. According to the National Center for Drug Abuse Statistics, almost 50,000 people die every year from opioid overdose; over 10 million people misuse opioids in a year; and opioids are a factor in at least seven out of 10 overdose deaths (72%).As a response to this epidemic, the Substance Abuse and Mental Health Services Administration (SAMHSA) is awarding $123 million in funding to provide multifaceted support Highly Recommended by Medicare: Professional Administration of MSAs as a Safety Measure When Frequently Abused Drugs are Involved
Shawn Deane, Esq., CMSP-F, General Counsel, Ametros COVID-19 has completely overshadowed certain health issues. The opioid epidemic has taken a back seat to the current pandemic. In 2019, 1.6 million Americans had an opioid use disorder and 10.1 million people misused prescription opioids. HHS citing the 2019 National Survey on Drug Use and Health, 2020. While the COVID-19 pandemic persists, data suggests that “[t]he nation’s COVID pandemic made the nation’s drug overdose epidemic worse.” See American Medical Association Issue Brief. Membership Advantages
Monica Williams, RN, CCM, CRRN, MSCC, CMSP, MSP Director, Innovative Claims Strategies, Co-Chair, MSPN Membership Committee MSPN provides professionals opportunities to form relationships that will enhance your practice. Joining MSPN and becoming active in the different committees gives our members a voice. Our organization has some of the best in the industry involved in MSP legislation to drive improvements. Networking with colleagues to problem solve complex case issues is a part of what we do. How to Prepare Your Client for a Trust Administrator
Joanne Marcus, MSW, Executive Director of Commonwealth Community Trust (CCT) You have won the case for your client; however, the procedure for disbursing the settlement funds may not always be as simple as writing a check. When working with clients who have special needs or who are receiving means-tested public benefits such as Medicaid and Supplemental Security Income (SSI), the next step in the settlement process may be to recommend a pooled special needs trust organization to administer your client’s well-deserved funds. Beware of Problematic Medicare Secondary Payer Compliance Settlement TermsRasa Fumagalli, JD, MSCC, CMSP-F, Director of MSP Compliance, Synergy Settlement Solutions Platelet Rich Plasma InjectionsReva D. Payne, MS, CCM, CDMS, CLCP, MSCC, QRC, Vice President of Clinical and Medical Management, Marker 28 CMS Begins New Year with New Section 111 User GuideLogan Pry, Compliance Manager, Allan Koba Compliance Solutions READ MORE...
Conditional Payment Confusion Wreaks Havoc in SettlementRasa Fumagalli, JD, MSCC, CMSP-F, Director of MSP Compliance, Synergy Settlements The practice of law requires lawyers to represent their clients zealously and competently. The American Bar Association’s Model Rules for Professional Conduct state that “competent representation requires the legal knowledge, skill, thoroughness and preparation reasonably necessary for the representation.” When representing a Medicare beneficiary in a personal injury case, competent representation also requires a good understanding of the impact of the Medicare Secondary Payer Act on the settlement. It is also important that Medicare Secondary Payer Compliance service providers provide competent advice to their clients. The Osterbye v United States, 2020 U.S. Dist LEXIS 116591 (June 30, 2020) case highlights the havoc that conditional payment confusion may cause in a case. In Osterbye, the United States District Court for the District of New Jersey was presented a Motion to Dismiss the Osterbye complaint based on the parties’ settlement agreement and a statute of limitations defense. The Court denied the motion and declined to dismiss Plaintiffs’ claims. Submit vs. Non-Submit
Monica Williams, RN, CCM, CRRN, LNC, MSCC, CMSP, MSP Manager, Innovative Claims Strategies CMS recommends the submission of Workers Compensation Medicare Set Aside (WCMSA). The recommended requirement is to protect Medicare’s interest for future medical expenses related to injuries, illness, or disease. There are no statutory or regulatory provisions that require submission, thus it is a voluntary process. CMS has established WCMSA review thresholds policies and procedures that must be meet prior to submission. MSA providers are tasked with assisting the parties involved with the WCMSA Guidelines for legal submission. There are some states where submission is not necessary because ongoing responsibility for medicals remain open. On the other hand, there are states that require the state worker’s compensation board approval and submission to Medicare for approval. Medicare Addresses Opioids in Professional AdministrationShawn Deane, Esq., General Counsel, Ametros In version 3.0 of the Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide, the Centers for Medicare & Medicaid Services (CMS) announced, for the first time, a specific use case where it highly recommended professional administration: “CMS highly recommends professional administration where an individual is taking controlled substances that CMS determines are ‘frequently abused drugs’ according to CMS’ Part D Drug Utilization Review (DUR) policy.” Sec. 17.1. CMS has identified opioids and benzodiazepines as frequently abused drugs. These medications are common in Medicare Set Asides (MSAs) and it is critical that parties to a settlement take CMS’s guidance into consideration when deciding how the MSA will be administered. With these guidelines, CMS is placing a greater emphasis on an individual’s safety. Ethical Practice Considerations for 2021
Monica Williams, RN, CCM, CRRN, LNC, MSCC, CMSP Many professions are governed by a code of ethics. A code of ethics is intended to ensure that professionals act responsibly and are open to correction. Medicare Set-Aside allocations may be provided by a variety of professionals such as nurses,
claims handlers and attorneys. This article will explore the ethical concept of neutrality related to Medicare set aside (MSA) preparation and the allocators need to strive for accuracy. Overview of MSA Accounts
Joanne Marcus, MSW, Executive Director, Commonwealth Community Trust This is the second article in a two-part series discussing First-Party PSNTs and Medicare Set-Aside (MSA) accounts. This article will provide an overview of MSA accounts and discuss the advantages of nesting an MSA account inside a First-Party
PSNT.
Benefits of a Pooled Special Needs Trust for Clients with Special Needs
Joanne Marcus, MSW, Executive Director, Commonwealth Community Trust This is the first article in a two-part series discussing Pooled Special Needs Trusts (PSNTs) and Medicare Set-Aside (MSA) accounts. This article will present an overview of PSNTs, their benefits, how to set up a PSNT for a client with special
needs, and what to do for clients who also need an MSA. CMS Allocations Contrary to Real-Life Practice?
Nahla D. Rizkhalla, PharmD, MSCC, Senior Clinical Pharmacist, ExamWorks Clinical Solutions Center for Medicare and Medicaid Services’ (CMS) focus is to protect Medicare’s interest when there is a primary payer on reported claims. The goal of a Workers’ Compensation Medicare Set-Aside Allocation (WCMSA) is to estimate the total cost that is incurred for all medical expenses reimbursable by Medicare for work-related conditions during the course of a claimant’s life, and to set aside sufficient funds. Pricing of medications within MSAs is done per the lowest non-repackaged generic average wholesale price (AWP) in accordance with CMS’ recognized and approved compendium, Micromedex® Red Book®. This amount proposed in the WCMSA is reviewed for adequacy of protecting Medicare’s interests. Discussed below are two CMS determinations for packages which cannot be separated or broken into smaller dispensable packages. Bearing in mind that packaging for medications typically correlates with the FDA approved labeling for use. One determination was returned from CMS as counter-higher and the other as a counter-lower; depicting discrepancies between real-world pricing and that of CMS. The PAID Act: Transparency in Medicare Part C and D Enrollment Would Improve Medicare Benefit Coordination
Heather Sanderson, CLO, FS Claim Solutions; Jason Lazarus, CEO, Synergy Settlements Congress created the Medicare Secondary Payer (MSP) program in 1980 to protect the Medicare Trust Fund. Under the MSP program, Medicare is prohibited from being a primary payer in instances where a Group Health Plan or a Non-Group Health Plan
(NGHP) – such as workers’ compensation, no-fault or liability insurance – is legally responsible for paying for medical treatment first on behalf of a Medicare beneficiary. The MSP law further requires Medicare to recover “conditional payments” it already made for treatment that the primary payer was responsible for. If Medicare is not reimbursed, it is authorized to take legal action and may recover double damages from plans that fail to repay it. Traditional Medicare (Parts A and B), as well as private Medicare, can make conditional payments. Diagnostic Studies in the Allocation: Guiding Principles
Julie Garrison, JD, MSCC, CMSP, Nyhan, Bambrick, Kinzie & Lowry Almost every Workers’ Compensation Medicare Set-Aside (WCMSA) includes future diagnostic imaging studies, usually x-rays and MRIs. For most work injuries, and especially orthopedic ones, diagnostic imaging studies are commonly done early in treatment. They may be done on an emergent basis. And it is not unusual for repeat studies to be conducted for more serious and/or ongoing conditions. This article will provide an overview of diagnostic imaging allocation per the WCMSA Reference Guide, Official Disability Guidelines, and other physician and standard of care guidelines as well as strategies for allocating future imaging studies. Georgia 400-Week Statutory Limitation on Medical Care Limits MSAs
Daniel Anders, Esq., MSCC, Chief Compliance Officer, Tower MSA Partners Obtaining CMS recognition of state statutory limitations on medical care in order to limit the MSA allocation has always proven difficult, but not impossible.This month's featured article by Daniel Anders, Chief Compliance Officer for Tower MSA Partners, discusses the statutory limitation on Medical Care Limits MSAs. As those who have Georgia WC claims know, since July 1, 2013, the state limits medical care in non-catastrophic comp claims to 400 weeks from the date of injury.While this is old news, payers may not recognize the statute’s potential impact on MSAs. If certain conditions are met, CMS will agree to limit the MSA based upon the 400-week limitation. Anticipating Section 111 Reporting Civil Monetary Penalties
Logan Pry, Esquire, Associate Attorney, Medicare Compliance, Gordon, Rees, Scully, Mansukhani On April 20, 2020, CMS closed its period for public comment on the notice of proposed rulemaking with regard to the civil monetary penalties that may be applied for noncompliance with the Section 111 Mandatory Insurer Reporting guidelines. With the public comment period closed we are now forced to sit and wait for CMS’ final determination regarding this proposal and whether it will institute final regulations regarding the imposition of civil monetary penalties for erroneous Section 111 reporting. The Truth About "Legal Zero" Allocations
Annie Davidson, Senior MSP Compliance Counsel and Policy Strategist, ExamWorks Clinical Solutions Many organizations have certain protocols which they follow when it comes to addressing Medicare’s interests in certain settlements. This month’s featured article by Annie M. Davidson, Senior MSP Compliance Council and Policy Strategist for ExamWorks Clinical Solutions, discusses “legal zero” Medicare Set-Aside allocation recommendations. ICD10 Codes and You
Joseph Gregorio, Attorney, Nyhan, Bambrick, Kinzie & Lowry Last month, NAMSAP shared information regarding the arrival of proposed regulations addressing Section 111 Civil Monetary Penalties. One of the categories that may involve the imposition of Civil Monetary Penalties deals with a party’s submission
of responses to recovery efforts that contradict reporting. Civil Monetary Penalties are Finally Here
Published by MSPN (formerly NAMSAP) The proposed regulation issuing guidance about Medicare Secondary Payer Civil Monetary Penalties relative to Section 111 reporting was unofficially disseminated on February 13, 2020. The official document was published in the Federal Register
on February 18, 2020 and is available online athttps://federalregister.gov/d/2020-03069. |
11/19/2025
November Webinar: Section 111
12/17/2025
December Webinar: Ethics
The relationship between The National MSP Network and CMS officials has been invaluable to my business. When the industry identifies concerning trends or questions, MSPN reaches out to CMS to get answers, work through problems and weigh
in on potential policy changes. I can always turn to MSPN to help my business navigate these ever-changing waters.
