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Don’t Ignore Non-Medicare Covered Damages in Catastrophic Workers’ Compensation Cases

B. Josh Pettingill, MBA, MS, MSCC

Are you relying on the carrier’s expert for projecting your client’s future medical expenses? Was your client compensated on your last catastrophic settlement for all future medical exposure or just the Medicare-covered items?  It is vital to have a comprehensive independent evaluation completed for future medical care. In most instances, the carrier is not evaluating the claim based upon all of the future medical exposure. There are many items not covered by the Medicare set-aside (MSA) which must be considered to fully evaluate future medical damages. Some examples of care frequently not included are the following:

  • Long-term, attendant and custodial care
  • Dental care
  • Non-Medicare covered medications
  • Eye examinations related to prescribing glasses
  • Dentures
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids and exams for fitting them
  • Routine foot care
  • Transportation
  • Home modifications

The Value of an Independent Evaluation of Future Medical Costs

With a comprehensive independent evaluation of future medical costs, you can address the following:

  • Is the defense’s MSA report accurate?
  • What is the value of future, non-Medicare covered expenses?
  • What is the amount of the “donut hole,” and any other out-of-pocket costs your client may incur?

Not only can an independent evaluation determine the value of non-Medicare covered items, but you can have an expert review the carrier’s MSA report to ensure the correct rated ages were used, the line items included in the report were accurate, and that the proper pricing was utilized. The MSA review alone will help bring to light any inaccuracies with the MSA, as well as help get a speedy turnaround for CMS approval.  As a bonus, you get the non-Medicare covered expenses fully quantified.

Case Study for an Independent Evaluation of Future Medical Costs

In a recent case, Synergy was asked to provide a medical review for an MSA with a value of $262,000. After reviewing the MSA report, it was determined the carrier’s MSA expert failed to properly price four of the six drugs included in the MSA. Upon further examination of the medical records and payouts, it was also determined one of the drugs should not have been included in the MSA report, as it was considered a non-Medicare allowable for CMS’ purposes. This drug alone accounted for $135,000. When the correct pricing was used for the MSA and the non-Medicare covered drug removed, the MSA went down slightly but the overall medical exposure increased by nearly $400,000.  This was due to the potential out-of-pocket expenditures for the “donut hole” and accounting for the non-Medicare covered drug.

This is just one of countless examples Synergy sees on a regular basis. It is imperative to have an independent plaintiff-based advocate on your side that is looking out for your client’s best interests and can protect your firm from any legal malpractice traps involving Medicare set-asides or future medical exposure.  Synergy can help make sure that you can focus on what you do best.  We can protect your client and your firm to make sure future medicals aren’t an issue in your next settlement.

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