MSPRC announcement regarding “Self-Calculated Final Conditional Payment Amount” Option

Medicare Set-Aside Blog on December 16, 2011 | Posted by

Beginning in February 2012, for settlements of $25,000 or less involving physical trauma based injuries where treatment has been completed, the beneficiary or their representative may be able to obtain a final conditional payment amount prior to settlement. The beneficiary/representative may calculate the final conditional payment amount utilizing information obtained from the MSPRC, the MyMedicare website or other claims information to calculate a proposed final conditional payment amount. The proposed conditional payment amount is then submitted to the MSPRC who will review the amount and if determined to be accurate, will provide the beneficiary/representative with a final conditional payment amount within 60 days. The case must then settle within 60 days of Medicare’s response.


The following criteria must be met in order to elect this option:

The liability insurance (including self-insurance) settlement is for a physical trauma based injury. (This means that it does not relate to ingestion, exposure, or medical implant), and
The total liability settlement, judgment, award, or other payment is $25,000 or less, and
The date of incident occurred at least six months before the beneficiary/representative submitted the proposed conditional payment amount to the MSRPC.
The beneficiary demonstrates that treatment has been completed and no further treatment is expected through a written physician  attestation or by certifying in writing that no medical treatment related to the case has occurred for at least ninety days prior to submission of the proposed conditional payment amount to the MSPRC.

The complete explanation, with instructions on how and when to elect this option, are expected to be posted on the website by January 15, 2012.

Of note, the announcement indicates that this is an initial step in providing Medicare’s final conditional payment amount prior to settlement and CMS plans to expand this option as it gains experience with the process.