Medicare Compliance

ECS’ MSAs are written reports that outline future care and prescriptions covered and otherwise reimbursable by Medicare so as to accurately estimate the total costs expected to be incurred for future Medicare-covered treatment related to the alleged injury during the course of a claimant’s / plaintiff’s life, and to set aside sufficient funds from the settlement, judgment, or award to cover those costs. ECS MSAs are prepared by our team of in-house MSCC-certified allocators. ECS has completed more MSAs than any other entity and has decades of experience unmatched by our competition. Our MSAs are prepared using medical evidence contained within a claimant’s / plaintiff’s medical and pharmacy records using policy guidance from the Centers for Medicare and Medicaid Services’ (CMS) and / or other relevant evidence-based guidelines and practices. ECS’ Doctors of Pharmacy collaborate on each report to ensure accurate prescription allocations and to identify prescription mitigation opportunities as well. These are designed to be submitted to CMS when the total estimated settlement value in a Workers’ Compensation case exceeds the applicable workload review threshold.

These "non-submit" allocations are written by our MSCC-certified allocators in accordance with Evidence Based treatment guidance (American College of Occupational and Environmental Medicine (ACOEM) and Official Disability Guidelines (ODG)) and not “because CMS says so”. They are written in collaboration with other in-house credentialed professional experts as appropriate: ECS’ Doctors of Pharmacy and Licensed Attorneys. These allocations account for concepts that CMS does not, like: comparative fault, the likelihood of prevailing at trial, apportionment and compromise, policy limits, strong defenses, evidence of secondary gain, independent medical evaluations, etc. Leveraging these allocations, the parties may still satisfy their obligations to consider Medicare’s future interest in their settlement pursuant to the MSP Statute. In many instances, these allocations are available for ECS indemnification for a one-time fee. While typically considered to be “non-submit” allocations, some parties do choose to submit these to CMS in Workers’ Compensation cases where the applicable workload review threshold is met. Often those parties are able to achieve approval of a lower dollar MSA amount than if they had submitted a “traditional” MSA.

When a case is complicated and the treatment path unclear, an ECS Medical Cost Projection (MCP) provides adjusters and defense attorneys with a chronological overview of the claimant’s medical treatment and professional documentation for future medical needs by identifying both Medicare-covered and non-Medicare-covered expenses. It is a dynamic report designed for updating and adjustment throughout the life of any claim to keep ongoing care and costs accurate and current, and can provide better insight for setting claim reserves. ECS’ Certified Life Care Planner RNs develop these MCPs based on review of records and physician recommendations along with professional experience, training and knowledge. They utilize Standards of Care, research, historical data, and pricing obtained via fee schedule, usual and customary charges, and bill reviews, etc. The action plan helps adjusters and attorneys manage the claim more effectively without compromising medical care. In addition, an outline of recommendations is developed when ‘red flags’ are identified and mitigation opportunities exist. Add the optional Medicare Covered Items (MCI) spreadsheet and gain a concise view of expenses to include in the settlement reserves.

An ECS LCP is a dynamic report, based on published standards of practice, comprehensive assessments, and data analysis/research, and its purpose is to establish and quantify medical damages from an injury, as well as take into consideration any possible items or services a claimant / plaintiff evaluee will need to maintain the highest level of independence and function throughout their life expectancy. LCPs are used by plaintiff and defense to understand damages and to establish the future medical value of a claim. They play a key role when a claimant or plaintiff is on Medicaid and the parties need to utilize a Special Needs Trust or Pooled Special Needs Trust.?

An ECS LCPR provides an objective, disciplined, and verifiable reviews of an existing LCP that meet the claimant / plaintiff’s future medical needs. These reports validate or provide the clinical foundation to challenge the existing LCP with an objective, reproducible, and transparent process. Analysis includes accurately assessing a claimant’s / plaintiff's future medical needs and functional limitations, plus an outline of the costs associated with future medical and pharmacy expenses, as well as vocational and architectural needs. Like our LCP reports, these are prepared by ECS’ tenured and credentialed RNs with an average 30 years’ experience in the medical field. They utilize "usual and customary" pricing in the geographic area where the claimant / plaintiff evaluee lives or the state where the claim originated. Our experts are laser-focused on objectively analyzing the existing LCP to aid relevant stakeholders in evaluating the future medical exposure and ultimately reaching settlement.

ECS offers a full suite of customizable Section 111 reporting programs to meet your compliance needs and avoid costly Civil Money Penalties. From fully integrated solutions for large enterprises to hybrid and direct-entry options for small and mid-size companies the Mandatory Insurer Reporting Suite ensures timely and accurate reporting with proactive data validations to ensure no reportable claim is left behind. ECS has a sophisticated data warehouse that automatically links Section 111 reporting data to use in resolving conditional payments and PAID Act recovery cases, and help identify Medicare Set-Aside claims, allowing for customized management reports linking all aspects of MSP compliance. Our system receives data from over 700 separate data sources (TPAs, Carriers, Employers, Attorneys, etc.) and can provide a single page snapshot of your claims data.

ECS provides ad hoc and comprehensive programmatic Conditional Payment (CP) and PAID Act recovery solutions to remove the worry, inconvenience, and liability of adjuster-handled disputes and appeals. Prior to settlement, ECS can automatically capture, quantify, and resolve your dispute and appeal possibilities with our programmatic approaches: CP Monitor, CP Protect, and CP Assure. This early data capture, combined with our programmatic disputes and appeals reduces Treasury collection incidents by over 70% and total amounts owed by upwards of 95%.

Additional ECS Services

• Pre-MSAs
• Claims Settlement Allocations (CSAs)
• CMS Submission of an MSA
• Legal Nurse Review
• Resolution and Mitigation Services
• MSA Mitigation, Claim Mitigation, Physician Outreach, and Outcome Management