Ametros Study Proves Post-Settlement Medicare Denials Happen

WILMINGTON, Mass.–(BUSINESS WIRE)–In a first-of-its-kind study, Ametros found that more than 34,000 claims a year were denied to Medicare beneficiaries after settlement because Workers’ Compensation Medicare Set Aside (WCMSA) funds were responsible payments.

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

Despite this, many industry players have questioned whether Medicare ever denies claims. Ametros, the leader in post-establishment medical administration, set out to find out. Together with ResDac researchers, Ametros analyzed Medicare Part B claims data from 2018 to 2020 and published “A study of CMS policy on treatment denials for injured workers with a Medicare set aside.”

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

“Analysis shows that Medicare consistently denies MSA beneficiary claims after settlement when it believes beneficiaries 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 the settlements to ensure that Medicare’s interests are taken into account and that the injured person receives professional administrative support with their annual MSA report at Medicare after settlement.”

The report provides a state-by-state table of denial breakdowns along with definitions and explanations of Medicare and MSA secondary payer terms, how CMS tracks MSAs, and the administration and compliance obligations of the MSA after settlement. Download “A Study of CMS Policy on Denial of Treatment for Injured Workers with Laid-Off Health Insurance” at ametros.com/medicaredenials.

Ametros will present the study results during a webinar on February 15 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 to thousands of members who receive funds from workers’ compensation and liability settlements. Based in Wilmington, Massachusetts, Ametros can be reached at 877.275.7415 or via www.ametros.com.

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