Medicare Compliance

ExamWorks Compliance Solutions (ECS) 

ExamWorks Compliance Solutions is a leading authority on Conditional Payment Resolution, Medicare Set-asides (MSAs), Evidence-Based MSAs, and MMSEA Section 111 Reporting. Leveraging our team of Nurses, Certified Life Care Planners, Doctors of Pharmacy, and Attorneys we deliver accurate and defensible Legal Nurse Reviews, Life Care Plans, Field Case Management and settlement strategies on a superior technology platform that enables efficient communications and delivery of our services.

Specialties – Conditional Payment Resolution, Medicare Set -Asides, Evidence-based MSAs, Mandatory Insurer Reporting (MMSEA Section 111), Medical Cost Projections, Life Care Plans, Legal Nurse Reviews, Demand Package Reviews, and Pharmacy / Opioid Mitigation.

Projecting the future Medicare covered medical needs for a claimant “post settlement” is complex. ExamWorks utilizes a cross functional team of experts to include Nurses certified as Life Care Planners, Doctors of Pharmacy, and Attorneys assuring the MSA that is created aligns with Medicare’s expectations and will be approved when submitted to CMS for their review and approval. ExamWorks has completed more MSAs than any other entity and has decades of experience unmatched by our competition.

 

Medicare Set-Aside (MSA) Allocations

Projecting the future Medicare covered medical needs for a claimant “post settlement” is complex.  ExamWorks utilizes a cross functional team of experts to include Nurses certified as life care planners, Doctors of Pharmacy, and Attorneys assuring the MSA that is created aligns with medicare’s expectations and will be approved when submitted to CMS for their review and approval.  ExamWorks has completed more MSAs than any other entity and has decades of experience unmatched by our competition.

Life Care Plan (LCP)

A Life Care Plan, a dynamic document based on standards of practice, is a comprehensive assessment that relies on data analysis and research to project medical expenses and contingencies related to an injury. The values for each future care recommendation are itemized, researched and documented according to standard Life Care Planning methodology, as defined by the International Academy of Life Care Planners. Our Life Care Planners have the qualifications and knowledge required to defend the reports if litigation is necessary.

Medical Cost Projection (MCP)

MCP is a comprehensive and cost-effective solution to forecast future medical exposure and establish an accurate basis upon which to set reserves and identify cost drivers for workers’ compensation claims and liability files. By accurately projecting future medical exposure, our MCP service becomes an invaluable negotiation tool for mediation and settlement.

Conditional Payment Services (CPS)

A conditional payment (CP) is essentially a Medicare lien in which they expect reimbursement.  Unfortunately many conditional payments are initiated by Medicare’s contractor based on Mandatory Insurer Reporting. Handling the demands for reimbursement and handling them timely requires clinical expertise and a program that assures all conditional payments are handled, disputed, mitigated, and tracked.  ExamWorks CP Assure, CP Protect, and CP Monitor programs allow clients to have full visibility into the status of their conditional payments and that they are handled prior to reaching the Treasury Department.

Mandatory Insurer Reporting (MIR)

Section 111 of the Medicare and Medicaid SCHIP Extension Act requires that certain claims involving Medicare eligible injured parties be reported to CMS in a specific format and timeline.  Failure to comply may result in a penalty of up to $1,000 per claim per day. ExamWorks' MIR platform provides proactive data validations to ensure data is accurate and acceptable to CMS standards and includes several methods of integration, from manual data entry to full EDI exchanges.  By analyzing the client’s MIR data, the platform automatically identifies claims with MSP exposure, thus protecting them from potential fines, penalties and litigation post-reporting.

Medicare Compliance Services

  • CMS Submissions
  • Conditional Payment Research
  • Conditional Payment Negotiation
  • Life Care Plans
  • Medical Cost Projections
  • Medicare Set-Aside Allocations
  • MSA Resolution and Mitigation Services
  • Rx Analysis and Outcome Management

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ExamWorks Medicare Compliance Portal

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