Ask Annie: MSAs and the “You Break It, You Buy It” Policy

Question: We are trying to settle a workers’ compensation claim with a Medicare beneficiary for $50,000. The claimant sustained an admitted right shoulder injury. He has unrelated neck issues from an old car accident. He and his treater are trying to argue the shoulder injury exacerbated his preexisting neck condition. We have denied the neck… Read more »

Ask Annie: Complex Settlements, Simplified

Question: We are settling a complicated claim involving a claimant’s lower back. Over the course of the claimant’s workers’ compensation claim they added a number of additional dates of injury (DOI) that involved no additional treatment, but each of these has its own claim number and we are hoping to resolve the entire matter in… Read more »

Ask Annie: When can I safely terminate ORM?

Today’s question implicates Medicare’s mandatory insurer reporting requirements. Identifying and understanding how to fulfill these obligations is an important element to claims handling, made critical by the proposed regulations outlining whether and how Medicare may penalize noncompliant entities.

Ask Annie: The Amended Review Process in Detail

A “counter-higher” refers to a specific type of determination issued by Medicare with respect to a submitted Workers’ Compensation Medicare Set-Aside Allocation (WCMSA). The question posed presumes the parties are settling for an amount that exceeds one of Medicare’s workload review thresholds: $25,000 for a case involving a Medicare beneficiary or $250,000 for a case involving a claimant with a “reasonable expectation of Medicare enrollment within 30 months of the date of settlement.”

Ask Annie: Mythical Zero Allocations

A “zero allocation” is what we call not setting money aside to pay for a claimant’s post-settlement Medicare-covered medical needs. A zero allocation is possible in two situations.

Ask Annie: SSDI and Medicare’s “Reasonable Expectation” Analysis

Question: Annie, in ExamWorks’ last webinar, Marty and Christie discussed CMS’ updated guidance for cases that don’t meet review thresholds. I’ve heard from some people that if an individual has ever applied for SSDI, they have a reasonable expectation of Medicare enrollment within 30 months. Is that accurate? Can you recap CMS’ updated guidance and what constitutes reasonable… Read more »

Ask Annie: Mysterious Conditional Payment Demands

This new column highlights practical ways to resolve critical Medicare Secondary Payer compliance questions. Annie Davidson and other ExamWorks experts will answer common and topical MSP compliance questions. Annie’s aim is to simplify complex issues that are encountered every day. We hope that you engage and profit from the forum. If you have a question that needs answers,… Read more »