Medicare by the numbers

In order to make the Medicare red flags stand out for you, the following numbers should become part of your adjusting knowledge:

  • 0 – the number of days a claimant must wait before filing for Social Security Disability after an injury or disability
  • 5 – the waiting period in months before claimant begins receiving Social Security Disability Insurance
  • 24 – the number of months on Social Security Disability before a claimant becomes Medicare eligible
  • $25K + – the minimum amount of a settlement (including the MSA) required for CMS review of your MSA (called the CMS review threshold)
  • 90-120 – the number of days it takes CMS to review an MSA (if they all info they need)
  • 100% – the amount of the C&R settlement CMS considers as future medical monies if they are not considered in the settlement

Call or write if you have questions.  I will be in your office this week and happy to discuss cases you may be considering for settlement. Have a great week!

Medicare Set Aside Arrangements in Special Needs Trusts

One of the oft overlooked aspects of a special needs trust is the creation of a Medicare Set Aside arrangement (MSA).  An MSA is a projection of future Medicare costs over the lifetime of a plaintiff.  This money is earmarked for future injury-related costs that would otherwise be paid for by Medicare.  While there are nor set guidelines for reviewing injury suits that do not involve workers compensation, the Centers for Medicare/Medicaid Services (CMS) requires such settlements to reasonably consider Medicare’s interests and cites an MSA as the preferred method for illustrating a client’s future medical costs and their intent on considering Medicare’s interests.  It’s important that an MSA be embedded within a special needs trust so that the reserved funds will not to be counted as “available resources”.

Why do we need an MSA?

The most common mistake in the liability and special needs arena is the failure to consider Medicare’s interest in a settlement or establishment of a trust.  Failing to imbed an MSA in a special needs trust allows the MSA funds to be considered a countable resource, which can render the beneficiary ineligible for means-tested government benefits.  You can protect your client’s interests further by securing MSA monies using a qualified insurance annuity (structured annuity).  A structured annuity will allow for regular and timely benefits that are in most cases tax-free.  Failure to consider Medicare’s interests may also open the beneficiary to Medicare recovery efforts and possible loss of Medicare benefits.

Ensuring fund availability

In most cases involving less than $100,000, it makes sense for MSA funds to be self-administered. Medicare Set Asides involving greater amounts are likely best administered by a professional administrator or custodian.  Funds can also be dispersed using a special claim payment debit card.

Who we are

BMA West was founded in 2006 and provides expert Medicare Set Aside projections and supporting services to attorneys and their clients across the nation.  A grass roots team of expert nurses and experienced insurance professionals, our purpose is to ensure the protection of the beneficiary’s Medicare benefits, while helping to simplify and secure a client’s use of future medical care monies.

Feel free to call or write to discuss or refer a case!

(949) 830-2027 or glortiz@bmawest-msa.com

Pro-F.I.R.M. moves on!

At the CWC conference in Dana Point, California, I attended a breakout session called Women in Risk Management.  There at the speakers podium was Angel Guerra-Chagolla, a risk manager with Arzyta Bakeries and Jennifer Lund, Sr. VP of Globa Risk Capital Insurance proposing to a moderate-sized group of women to battle through the industry biases and seek mentorship from established risk managers.

While the session seemed a bit more impromptu and off-the-cuff, it did engage the audience with the necessary proactive measures needed to further a woman’s career in the risk management field.  They did both emphasize the various gender characteristic differences that could make a woman successful in the field of risk management.  Those would include the ability for most women to show empathy and to relate better with employees rather than take an authoritative approach to workplace challenges, as would most male counterparts.  That aspect of the session struck a nerve and did cause me to reflect.  I imagine that with some reflection, networking opportunities, training and mentorship, it won’t be long until the ranks of risk managers begin to even out.

Ms. Guerra-Chagolla will be hosting a networking and empowerment event for female insurance professionals called Sisters in Business: A Female Empowerment Seminar September 27, 2018 at the Dave & Busters Event Center in Ontario, CA from 10 to 3 p.m.  You can RSVP for this event at angel@theprofirm.com

Best of luck!

 

Controlling the MSA outcome through a proactive approach

When your MSA projections comes back excessively high, you have to ask yourself … why?

Here’s twelve years of CMS submission experience: The most important thing to remember is to always have your documentation ready.  Denial letters; all medical records; medical payments made to the proper line of insurance; clarification of injured body parts complete with doctor opinion as to compensability and need for future treatment.  I always advise that self-insured employers adopt a proactive claims adjusting model.  Pursue the MSA well before the WCAB hearing in order to valuate the true value of the claim.  Anticipate when Medicare will become an issue and adjust the claim toward minimizing the long term cost of the claim, rather than the immediate cost of the claim.  Remember, a truly successful outcome occurs as a result of a proactive approach.  Keeping the injured worker treating within the MPN will eliminate the need of sending the claimant out to an AME or QME.  You see, CMS does not recognize the AME and will always base their review on the treating physician’s opinion.

Feel free to call or write with questions or to schedule a time to meet.

Have a great week!

Communities coming together to eliminate MS! MS Bay to Bay Ride 10/20 to 10/21/2018

Multiple sclerosis is an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain and between the brain and body.

Symptoms range from numbness and tingling to blindness and paralysis. The progress, severity, and specific symptoms of MS in any one person cannot yet be predicted, but advances in research and treatment are leading to better understanding and moving us closer to a world free of MS. Most people with MS are diagnosed between the ages of 20 and 50, with at least two to three times more women than men being diagnosed with the disease. MS affects more than 2.3 million individuals worldwide.  Find out more about multiple sclerosis at nationalMSsociety.org

On October 20 through October 21, 2018, team BMA West will ride 100 miles from Irvine to San Diego in an effort to raise funds to continue the fight against MS!  Along with over three thousand riders, the goal of this event is to raise awareness about life with MS and to raise funds to continue research and development of new treatments.  Last year, the MS 150 Bay to Bay ride raised close to, if not more than, $2 million dollars!  The goal is to reach $3 million in 2018!  We encourage our friends and family to participate!  You can volunteer to help during the weekend ride or grab a bike and start pedaling!  These rides occur across the country over the course of the year and is a fun an rewarding way to give back to the community!  Check out my link below!  A donation would be greatly appreciated!

Click here to visit my personal page.
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Obesity in the workplace. Discerning whether an employee is well enough to work

In the Journal of Occupational and Environmental Medicine in January 2018, researchers identify the link between obesity and workplace injuries and absenteeism.  Obesity is associated with sleep disorders, sleep apnea, diabetic symptoms, musculoskeletal issues, high blood pressure and depression.  In a Duke University study , showed workers with a body mass index (BMI) greater than 40 filed twice the number of workers’ compensation claims as non-obese workers.  A University of Texas-Austin study  showed that for workers with major injuries, a higher body mass index was associated with more expensive workers’ compensation claims.  That’s a lot of evidence.  So, here’s some quick notes.  Encouraging a healthy workplace can be as simple as offering discount coupons to the gym or offering healthier vending machine options.  Ideally, a cafeteria offering healthy foods would offer tremendous benefits, but I don’t think companies have offer those types of fringe benefits in the U.S. at the present time.  Instead, maybe your company’s Employee Assistance Program (EAP) can offer some options to promote a culture of good health in the workplace.  Regarding workplace injuries, there’s a fine line between discrimination and reassigning or removing an employee, because they’re physically not up to the task.  It’s highly important to recognize when an employee is at risk of injury or illness on the job.

Do’s and Don’t’s regarding nurse case managers that employers and examiners should know

After a while, claims professionals fail to define why they’re using nurse case management and what their expectations should be of those nurses.  I’ve seen folks put a nurse case manager on a case to act as a bulldog in order to get the injured worker’s

status expedited and question the validity of the doctor’s treatment plan.  But one thing is clear, before assigning a nurse case manager to a case, ensure that specific goals and objectives have been communicated to all parties and schedule monthly or bi-weekly  times to review the objectives.  In order to clarify the do’s and don’ts of nurse case manager utilization, below is a list included in a Lexis Nexis article written by Steve Birnbaum, The Case for Clear Guidelines for Nurse Case Managers Copyright 2012

“DO:

  1. Be inclusive of all parties involved in the medical recovery process, especially the family.
  2. Include goals and time frames when creating the care plan and allow for updates.
  3. Determine if treatment is appropriate.
  4. Determine what is needed for successful return to work, especially from employer’s perspective.
  5. Provide client advocacy and support at all times, and provide input and guidance on treatment services
  6. Use valid disability duration guidelines, and use them as GUIDELINES.
  7. Educate all parties, especially employer, whenever possible on the positive and cost-effective aspects of return to work programs and processes.
  8. Always obtain and maintain appropriate releases of information.
  9. Understand that there are many players in the case management process, but that your main client should always be the injured employee.
  10. At the very start, identify clearly your role as a case manager.

DON’T:

  1. Change employee’s doctor appointments just to fit YOUR schedule.
  2. Perpetuate disability by failing to address doctor recommendations, health concerns, or return-to-work issues in a timely fashion.
  3. Become personally and/or emotionally attached to the clients.
  4. Assume that you have an absolute right to attend all doctors’ appointments despite client wishes against it.
  5. Interfere with due process between employee and employer.
  6. Initiate cost services prior to obtaining carrier authorization.
  7. Provide legal direction to the claims adjuster, or engage in claims investigative or adversarial activities.
  8. Give legal advice at any time.
  9. Schedule independent medical examinations.

Added to these should be considerations of privacy under HIPAA (Health Insurance Portability and Accountability Act, 42 U.S.C.S. § 1320d et seq.) and a transparency of the relationship between the insurance company and the nurse case practitioner.”

Feel free to call us with questions or referrals at (949) 830-2027 or write us at glortiz@bmawest-msa.com or leave a comment!