legacy claims

Greg Gitter Offers Thoughts on CMS Re-Review Policy

Our very own Greg Gitter was recently interviewed as part of an article by our good friends at WorkCompCentral regarding some of the positive and negative effects of the Medicare Set Aside (MSA) re-review policy set forth by the Centers for Medicare and Medicaid Services two years ago.

 In 2017, CMS opened the door for a one-time re-review of an MSA provided the revised approval would result in a change to the MSA of at least 10% or $10,000, whichever was greater. Prior to this policy, CMS would only review and approve an MSA one time which could often leave settlement parties with no recourse if the approved MSA figure did not line up with the terms of their agreement.  In those instances, a decision was typically made to leave the file open and no longer pursue a settlement.  

 This policy change has been met with mixed results from our vantage point here at Legacy Claim Solutions. We often see instances where there have been drastic changes in treatment and medications subsequent to a CMS approval.  Previously those changes were irrelevant as the CMS approval was set in stone, however there is now an opportunity to position a file for a re-review which can re-open the door to negotiations and settlements, and we have had success with this process.  However, as the article states, parties must keep in mind the timeframe allowed for the one-time re-review.  In addition to the dollar or percentage requirement, an existing MSA approval must be between 12 and 48 months old to qualify.  Unfortunately, this stipulation eliminates many older files from the re-review consideration even though the treatment has changed dramatically.  We would like to see the timeframe requirement expanded to give these older MSAs an opportunity to be updated with current medical and prescription needs.  This would undoubtedly open the door to settlements on older cases that had been written off years ago.

 Overall, however, this has been a welcome change to the stale review policy that had been in place for years.  It is evident that CMS wants to work with the settlement community to improve the Medicare Secondary Payer compliance system when changes are needed.  We applaud the National Alliance of Medicare Set Aside Professionals (NAMSAP) for continuing their efforts to serve as the voice of the MSA industry.

 Please click here to visit our friends at workcompcentral.

Reversal of Medical Director’s Approval in Louisiana

We recently received a letter from an attorney colleague of ours in Louisiana, Wayne Fontana with Roedel Parsons Koch Blache Balhoff & McCollister, informing us he recently received a judgement out of District 07 which overturned a medical director’s decision approving a $40,000 knee surgery.  Of note, the trial judge “specifically determined that the knee surgery was not in accordance with the medical treatment schedule and thereby overturned the medical director’s approval.”  It has historically been very difficult, if not impossible, to overturn the opinions of medical directors in Louisiana.  This has resulted, in our opinion, in inflated costs of future medical care as unapproved and unnecessary care has to be accounted for at the settlement of a workers’ compensation claim.  Once improper decisions are rendered by a medical director, decisions are typically made to not approach a settlement due to the increased cost to do so. Hello legacy claim.

This reversal is noteworthy as it could open the door for an increased number of successful, and medically appropriate, appeals.  Mr. Fontana said to us via email, “The more people who know that this medical director should be challenged and that, with the right case, his rubber stamp approvals can be reversed, the better.”  To our Louisiana clients, it would be a good idea to review prior unfavorable decisions from medical directors and investigate whether or not you might have a case for a successful appeal.

To view the letter from Mr. Fontana, please click here.

Article Details Evolving Trends in Catastrophic Workers' Compensation Claims

We ran across an article by Insurance Business recently that details some evolving trends in catastrophic workers’ compensation cases.  We took a particular interest in this because while not all of the cases we assist in settling are catastrophic in nature, many of them are, and maintaining a keen understanding of the trends within the workers’ compensation industry helps us to better understand our client’s current approach to settling claims.  

 The article indicates the soft market experienced by the workers’ compensation industry over the last several years may be reversing.  There are a variety of factors that contribute to the current landscape of catastrophic workers’ compensation claims, including injury frequency, escalating costs of medical goods and services, and the advancement of modern medicine and procedures that prolong the life of injured workers.

 In our experience, these types of trends can elevate the status of a workers’ compensation claim from “standard” to “legacy” quick, fast, and in a hurry.  It simply becomes less and less advantageous to settle a claim when projecting the escalating costs of medical needs over one’s lifetime. It is imperative to get out ahead of these claims and implement mitigation strategies to help resolve them once and for all.  We are here to help bridge the settlement gap and assist our clients in tackling these difficult to settle cases in their entirety.

 Again, our thanks to Insurance Business for a very informative article that can be read by clicking here.