Outlining Medicare's Devilish Details

Guidelines require that workers' compensation managers cross their T's and dot their I's when they apply to Medicare for set-asides.

By CYRIL TUOHY, managing editor of Risk & Insurance®

The regulatory burden required to follow Medicare set-aside rules has become a cottage industry of details and paper-filing for workers' compensation managers and lawyers, said Jim Pocius, an expert on Medicare set-asides.

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From detailed information about the workers' compensation claimant, to medical records to the facts of individual injury cases, "You have to show them everything," said Pocius, an attorney and shareholder with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin in Scranton, Pa.

Pocius, one of the nation's foremost experts on Medicare set-asides, led the Wednesday session titled Think Tank on Medicare Issues Related to Workers' Compensation, at the 21st Annual National Workers' Compensation and Disability Conference® & Expo.

A Medicare set-aside is a monetary allocation created from the settlement of a workers' compensation case. It is established from a portion of the settlement amount to be used to pay future medical expenses that are related to the job injury and that would otherwise be payable by Medicare.

Years ago, lawyers would simply settle on an amount to set aside over the phone, Pocius said. But over the years, Medicare has required more documentation regarding workers' compensation set asides. There is now so much information to provide that it has literally blossomed into a "niche business," he said.

Workers' compensation managers said they have sometimes waited years for an answer from Medicare.

Pocius has seen some outlandish stories regarding Medicare set-asides. In one case, Medicare chose to award the estate of a war veteran who accidentally died of burns from a propane explosion a $150,000 windfall, while simultaneously disputing a separate $25.00 outlay. "They will pursue you for $25.00, even if they lose $150,000," Pocius said.

Workers' compensation managers who want to dispute Medicare over set-aside amounts should do so when they receive the so-called conditional payment letter, said Pocius, a former assistant professor at Marywood College in Scranton.

He also advised workers' compensation managers to be alert to Medicare using discovery in one set-aside case to probe into the details of another, unrelated workers' compensation set-aside case.

November 12, 2012

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