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.
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Have a great week!