Medicare Secondary Payer Services

Novare offers a full line of compliance driven solutions accompanied with personalized service from receipt to resolution.  Our experts perform a claim specific analysist and provide recommendations for cost saving solutions while ensuring that Medicare’s interest are taken into account.

All parties in a workers’ compensation case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare’s interests when resolving cases that include future medical expenses.  The recommended method to protect Medicare’s interests is a WCMSA.

Pursuant to 42 U.S.C. §1395y(b)(2) and § 1862(b)(2)(A)(ii), Medicare is precluded from paying for a beneficiary’s medical expenses when payment “has been made or can reasonably be expected to be made under a workers’ compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance.” Novare’s MSP services, taking Medicare’s interest into account:

Novare’s MSP services, taking Medicare’s interest into account:

  • Medicare Set Aside (MSA) Workers’ Comp and Liability
  • MSA Update
  • MSA Submission
  • Medical Cost Projection
  • MCP Update
  • MCP to MSA conversion
  • Life Care Plan
  • Conditional Payment Identification
  • Conditional Payment Dispute/Resolution
  • Final Document Submission
  • Medicaid Services
  • Medicaid Dispute/Negotiation
  • Medicare Check
  • Social Security Disability Verification
  • Rated Age Evaluation

Medicare Set Aside (MSA) Workers’ Comp and Liability

Novare MSAs are a Medicare compliant allocation that projects injury-related Medicare covered medical treatment, services and prescription needs over the claimant’s life expectancy. All MSA’s are prepared by a registered nurse, Certified Medicare Set Aside Consultants and or Certified Life Care Planners.

Records required for MSA preparation:

First Report of injury

2 years medical records

All surgical, procedure, Cat Scan and MRI reports (life of claim)

2 years pharmacy history

2 year all-inclusive payment history (separated by medical, identity and expense)

Claimant signed consent to release (if MSA is to be submitted to CMS for review/approval)

Medical Cost Projection

Novare Medical Cost Projections are produced by registered nurses, Certified Medicare Set Aside Consultants and or Certified Life Care Planners. Our MCPs are prepared through a comprehensive analysis, personal to the claimant’s medical needs and are case specific.

Required records and documentation:

  • 2 years Current medical records
  • 2 years Current pharmacy history
  • Claim payment history

MSA Update

Novare will provide updates and or revisions on all Novare MSAs when requested.

MSA Submission

Novare will formally submit the MSA and all required documentation to CMS for approval. Our team provides CMS all required documentation and supplemental information for review. Novare prepares all MSA allocations is anticipation of CMS submission, unless otherwise instructed by the client. Our mission is to submit a cost accurate allocation producing a CMS approval of “as submitted”.

CMS required records and documentation:

  • Claimant signed consent to release.
  • 2 years current medical record
  • All surgical, procedure, Cat Scan and MRI reports (life of claim)
  • 2 years current pharmacy history
  • 2 years current all-inclusive payment history (separated by medical, identity and expense)

MCP Update

Novare will provide updates and or revisions on all Novare MSAs when requested.

Required records and documentation:

  • Current treatment records
  • Current pharmacy records
  • Current 2 year all-inclusive payment history

MCP to MSA conversion

Novare will convert any Novare MCPs to an MSA upon request.

Required records and documentation:

  • First Report of injury
  • 2 years medical records
  • All surgical, procedure, Cat Scan and MRI reports (life of claim)
    2 years pharmacy history
  • 2 year all-inclusive payment history (separated by medical, identity
    and expense)
  • Claimant signed consent to release (if MSA is to be submitted to CMS for review/approval)

Conditional Payment Identification

A potential for conditional payments arise when an injured worker is a Medicare Beneficiary. Any injury related payments that are made by Medicare are made in expectation of reimbursement. Novare’s MSP professionals will make contact with the BCRC/CRC to initiate this process.

Required records and documentation:

  • Claimant signed proof of representation
  • Carrier signed letter of authorization (Placed on Carrier Letterhead)
  • Claimant current address, Date of Birth and Date of injury
  • Compensable Body Part (s)
  • Injury Description
  • Carrier name and contact information (address, phone and fax)
  • Attorney Information (if available)

Life Care Plans

Novare Life Care Plans identify future treatment cost for all services that will likely be needed over the individual’s lifetime. These reports are highly detailed and are specific to the individual and compensable
treatment needs.

Required records and documentation:

  • All medical records life of claim
  • Claim payment history
  • Pharmacy history

Conditional Payment Dispute/Resolution

Our Conditional Payment team will make a comprehensive review of CMS itemized medical payment made by Medicare in expectation of reimbursement .  A formal dispute of these unrelated charges will be submitted to the BCRC/CRC for determination of removal. Our disputes identify non- compensable charges for removal and are accompanied by supporting documentation.

Required records and documentation:

  • Claimant signed proof of representation
  • Carrier signed letter of authorization (Placed on Carrier Letterhead)

Final Document Submission

Upon request final documents will be formally submitted to the appropriate Medicare Contractor.

Medicaid Services:

Our MSP professionals offer complete resolution services; Medicaid identification, disputes, negotiations and resolution.

Required records and documentation:

  • Signed HIPPA release
  • Signed proof of representation
  • Letter of Authority
  • Medical records, judgments or awards.

Social Security Disability Verification:

A verification of Medicare and or Social Security Disability status.

Required Release:

  • Signed SSA-3288

Medicare Check:

A verification of Medicare Beneficiary status and eligibility dates.

Required information:

  • Claimant name
  • Current Address
  • Date of Birth
  • SSN
  • Responsible reporting entity number (RRE#)

Rated Age Evaluation:

A comprehensive review of medical records will be completed. A submission of the findings of this review along with medical record documentation will be submitted for a rated age evaluation. This evaluation will provide an appropriate life expectancy for allocation.

Required records and documentation:

  • Claimant medical records for review

Case Management

Novare provides best practices that help injured workers and reduces employer cost

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Utilization Management

We use licensed nurses and board certified physicians helping maintain cost.

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Medical Bill Review

Utilizes automated bill review software to maximize potential reductions for authorized payments.

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MSP Service

Compliance driven solutions with personalized

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