Friday FAQ: Is a Medicare Set Aside Necessary in My Case?



Question: I have a female client (DOB 10/23/1937) who sustained a minor hip fracture in March, 2009. She only treated for a few months (last treatment date was in May, 2009), and she has not received any medical treatment for that injury since May 2009. I do not believe that she was a Medicare beneficiary at the time of her injury, but I do know that Medicare made no conditional payments in connection with that injury. She is now a Medicare beneficiary. We have settled the case for $35,000. I am in the process of obtaining the final letter from Medicare (which I fully expect to state that there is no lien since no conditional payments were made).

Is this the type of case where a Medicare set aside may be necessary? The settlement is small and she has not treated for the injury in almost five years. I appreciate your thoughts.


Answer: While it may be unlikely in today’s environment (current Medicare Secondary Payer statute and final regulations) that an MSA would be required under such facts, best practices would dictate that the file has been documented to evidence that the issue was addressed at the date of settlement and the conclusions drawn were reasonable.

Actually, it is this type of case why we created our MSA Decision Engine. It allows a user to log into a secure web platform, answer a series of questions and arrive at a conclusion as to whether an MSA is warranted under those facts, the rationale for why such a conclusion was reached and then if an MSA is appropriate, the maximum amount for which the MSA would need to be funded. Priced at only $250 per file, it’s the lowest cost of compliance going today. If you are interested, click here to schedule your demo!

Medicare Set Aside Services

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