In a first-of-its kind study, Ametros found that over 34,000 claims per year were denied to Medicare beneficiaries’ post-settlement because Workers’ Compensation Medicare Set Aside (WCMSA) funds were responsible for the payments.

The Centers for Medicare and Medicaid Services (CMS) has long warned that it requires WCMSA funds to be used appropriately before Medicare benefits will pay for injury-related treatment. CMS’s WCMSA Reference Guide states in Section 17.3 “Medicare will deny all [workers’ compensation] injury-related claims until the WCMSA administrator can demonstrate appropriate use equal to the full amount of the WCMSA.”

Despite this, many in the industry have questioned whether Medicare ever denies claims. Ametros, the leader in post-settlement medical administration, decided to find out. Collaborating with ResDac researchers, Ametros analyzed Medicare Part B claim data from 2018-2020 and has published "A Study of CMS Policy on Treatment Denials for Injured Workers with a Medicare Set Aside."

Examining a random sample of five percent of the Medicare beneficiary population over a three-year period, researchers estimated Medicare denied 35,980 WCMSA claims in 2018, 36,060 in 2019, and 30,720 in 2020 because the individual’s WCMSA account should have paid the claims.

“The analysis shows that Medicare systematically denies MSA recipients’ claims after settlement when it believes recipients have MSA funds to pay for their injury-related care,” said Ametros CEO Porter Leslie. “This is a wake-up call for everyone involved in settlements to make sure that Medicare’s interests are considered and that the injured person receives professional administration support with their annual MSA reporting to Medicare after settlement.”

The report provides a state-by-state chart of denial breakdowns along with definitions and explanations of the Medicare Secondary Payer and MSA terms, how CMS tracks MSAs, and MSA post-settlement administration and compliance obligations. Download “A Study of CMS Policy on Treatment Denials for Injured Workers with a Medicare Set Aside” at ametros.com/medicaredenials.

Ametros will present the study’s findings in a February 15 webinar hosted by John Kane, Shawn Deane, and Jayson Gallant starting at 1 p.m. EST. Register here.

About Ametros

Ametros is the industry leader in post-settlement medical administration and a trusted partner for thousands of members receiving funds from workers’ compensation and liability settlements. Headquartered in Wilmington, Massachusetts, Ametros may be reached at 877.275.7415 or via www.ametros.com.

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