Professional Administration: The Last Piece of the MSP Compliance Puzzle

CMS, Medicare Set-Asides, Professional Administration on June 26, 2018
Posted by Jean S. Goldstein, JD, CMSP

Professional Administration is the last piece of the Medicare Secondary Payer compliance puzzleIt has been nearly one year since the Centers for Medicare & Medicaid Services (CMS) first released a revised Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide,[1] which addressed one of the lesser discussed topics in Medicare Secondary Payer (MSP) compliance: professional administration.  Specifically, the revised guide included the following statement: “[a]lthough beneficiaries may act as their own administrators, it is highly recommended that settlement recipients consider the use of a professional administrator for their funds.” (WCMSA Reference Guide, COBR-Q1-2018-V2.7, Pg. 55). (emphasis added.)  For those unfamiliar with the process, once a WCMSA (whether reviewed/approved by CMS or not) is established, the total WCMSA amount must be placed into an interest-bearing account, separate from any other personal accounts.  From this account, an injured worker must pay for all Medicare-covered services and treatment related to the work injury, and provide CMS with a yearly reporting of these expenditures. The WCMSA account must be appropriately exhausted before Medicare will begin to pay for care related to the industrial injury.  There are two options for administration of an established WCMSA account: self-administration and professional administration.  Self-administration requires that an injured worker manage the payments, manage the arrangements for the payments, and accounting on their own.  Professional administration involves a third party taking over the injured worker’s role of administering the MSA. 

As a provider of Medicare Secondary Payer compliance services, MEDVAL offers two solutions for administration of a WCMSA account: a self-administration assistance program for injured workers and professional administration.  In reviewing CMS’ statement from the revised CMS guide, it is crystal clear that CMS has endorsed professional administration.  The reasoning behind the endorsement is obvious to anyone who has ever struggled with balancing a checkbook.  Add in navigating payment arrangements with medical providers, determining whether treatment is Medicare-covered (and which treatment is not), on top of submitting an annual accounting attestation form to CMS- and it is no wonder that CMS has “highly recommended” professional administration.  The administration of a WCMSA account can be very overwhelming.  Moreover, the overarching concern of an injured worker spending WCMSA funds inappropriately, and Medicare being forced to pay prematurely, is one which is always present.  That is where professional administration comes into play.  With professional administration, the injured worker obtains the medical treatment they need, and the professional administrator handles all of the administrative burdens.  It seems simple, but there is a lot of knowledge required, both in negotiating payment arrangements and medical knowledge, to properly administer a WCMSA account.  Most importantly as recommended by CMS, “the WCMSA should be administered by a competent administrator.”  (WCMSA Reference Guide, Pg. 55).  The proper and careful management of WCMSA funds is paramount to ensuring Medicare coverage remains uninterrupted. 

Over the years, MEDVAL has professionally administered thousands of cases, and each case is more than just an WCMSA account to us.  Our clients have come to rely on us, and we truly believe it is our duty to advocate on their behalf and assist them as much as possible.  One of our clients, Tina, recently wrote to us, and asked that we share her experience in utilizing our professional administration service:

“Nearly 8 years ago I took over the care of my paraplegic brother who understandably has very complicated health care needs. As you can imagine this is a daunting task, however from the first time I reached out to MEDVAL…they became my guardian angels helping me through the maze of medical bills and dealing with the medical providers with regard to payment and adjustments of such. The professionals at MEDVAL have been instrumental in my ability to successfully watch over my brother making sure he has all of the healthcare professionals and procedures needed to maintain his quality of life as a paraplegic. Honestly their help, understanding and knowledge of the high cost of medical care in general is impressive.” (Tina Lucas, Portland, Maine)

Tina and her brother’s experience is just one example of the countless individuals we help daily.  Professional administration is the last piece of the Medicare Secondary Payer compliance puzzle, which ensures that MSA funds are spent appropriately, while removing the administrative burdens that an injured worker would otherwise be faced with. 

For questions and referrals regarding our professional administration services, please contact our team at: [email protected].

[1] Since July, 2017, an additional WCMSA reference guide has been issued, with very minor and less significant changes than the July version.