| Tier 1 - MSA Consultation, Waiver & Acknowledgement | Tier 1 - MSA Consultation, Waiver & Acknowledgement |
| Our service includes a telephonic consultation with the client to advise them regarding the Medicare “future interest” protection mechanisms. If they decline to create a set aside, we will prepare a customized waiver for the client to sign. If in person meeting is desired and travel time in excess of one hour is required, there is an additional charge of $250.00.* | $500.00 |
| Tier 2 - Estimate of Medicare Future Covered Services | Tier 2 - Estimate of Medicare Future Covered Services |
| This service includes preparation of a report outlining an estimate of the costs of future Medicare covered services for injury related care to determine amount to be set aside. It is used for cases where there is a small settlement and a formal allocation isn’t desired due to economic realities. | $1,500.00 |
| Reduction analysis, if appropriate, with estimate. For cases where damages are substantial when compared to the recovery | $2,000.00 |
| Tier 3 - Medicare Set Aside Allocation | |
| This service includes preparation of a complete Medicare set aside allocation report that complies with CMS requirements for submission. Normal turnaround time for set aside allocations is 10 days from the date we receive all necessary documents. If needed sooner, a rush fee will be applied (see below for amount). Set aside allocation fees include one revision to the report and all consultations. | |
| Workers’ Compensation Cases** | $1,750.00 |
| Workers’ Compensation and Liability Case Combined** | $2,000.00 |
| Liability Cases** | $2,250.00 |
| Medicare Set Aside Allocation Submission to CMS | Medicare Set Aside Allocation Submission to CMS |
| This service includes preparation of a complete package to present the set aside allocation for CMS review/approval. Please note that most CMS Regional offices refuse to review and approve liability Medicare set asides. | $1,000.00 |
| “No MSA”/MSA Evaluation Letter | “No MSA”/MSA Evaluation Letter |
| If it is determined that the MSA is not applicable, then Synergy provides a letter to counsel memorializing Medicare’s interests have adequately been taken into account. | $375.00 |
| Defense MSA Allocation Review | Defense MSA Allocation Review |
| This service provides the plaintiff with a report regarding the proposed allocation by the defense. Many times inappropriate items are included in the MSA driving the number upward. We work to determine whether it is possible to reduce the MSA. In certain cases, all care isn’t included and we outline what wasn’t included but should have been included. | $1,500.00 |
| Non-Medicare Expense Report & Donut Hole Evaluation | Non-Medicare Expense Report & Donut Hole Evaluation |
| This report is prepared for workers’ compensation cases to determine what items or services will not be covered by the set aside. It also outlines the donut hole amount for Part D. It is an invaluable tool for negotiating a workers’ compensation settlement. | $1,500.00 |
| Donut Hole Evaluation Only | $500.00 |
| Future Medical Cost Projection | Future Medical Cost Projection |
| This service provides a report similar to a life care plan that outlines all of the future medical needs both Medicare and non‐Medicare covered. Please note we do not provide expert testimony similar to life care planners. | |
| Non-Complex*** | $1,500.00 |
| Complex*** | $2,000.00 |
| Additional Fees | Additional Fees |
| Rush Fee | $500.00 |
| Hourly Charge for Revisions | $250.00/hr |
| Deposition Testimony | $250.00/hr |
| *This service does not include any medical review or cost projection. **Cases deemed “catastrophic” by Synergy will have an additional $250.00 fee applied. ***Complexity determined at intake. | $50.00 |
