Medicare Compliance

ExamWorks Clinical Solutions (ECS) provides a portfolio of Medicare compliance solutions and analytics ensuring regulatory guidelines are followed and excessive medical treatment or costs identified. Our applications, portals and settlement planning services navigate the dynamic conditions of the Medicare marketplace.  Our services keep clients informed and facilitate positive cost-effective outcomes. Services include Workers’ Compensation and Liability Medicare Set-Asides, Lien and Conditional Payment Resolution and Rx Analysis.

ExamWorks’ Galileo portal provides strategic intelligence that measure clients' compliance rates and assist in client stewardship activities.

Key features include:

  • MIR performance and compliance rates
  • Breakdown of TPOC amounts by line of business, ICD codes, geographic region
  • Trend data by jurisdiction and claims office
  • Ability to proactively rate claims handling practices

Case Management services are accredited by URAC.

Medicare Set-Aside (MSA) Allocations

ExamWorks utilizes informed expertise to provide Medicare Compliance services which determine a reasonable allocation of injury-related Medicare-covered medical expenses projected over the claimant's life expectancy. A portion of the settlement is then allocated to the MSA in either workers' compensation or liability cases. The allocation ensures that the burden of future injury-related medical care is not shifted to Medicare. When necessary, a prescription and treatment addendum are prepared, which empowers the adjuster with the knowledge and documentation to contain and often limit the MSA amount.

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 Resolution Services (CPS)

The first step in a Center for Medicare & Medicaid (CMS) submission process is the completion of an MSA. Our Medicare Lien/Conditional Payment services help clients navigate the Medicare system to secure the approval of settlements by the CMS. Medicare Liens/Conditional Payments must be discovered and resolved prior to settlement. Our Medicare Lien/Conditional Payment services work as the connection between the beneficiary and CMS or attorney to establish the Medicare reimbursement amount, and whether it is justified. We work to reduce the amount needed to resolve the claim.

Mandatory Insurance 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

  • Case Management
  • Life Care Plans
  • Legal Nurse Reviews
  • Medical Cost Projections
  • Medical Panel Advisory
  • Medical Director Consultations
  • Medicare Set-Aside Allocations 
  • MSA Resolutions
  • Medicare Secondary Payer
  • Nurse-to-Doc Negotiations
  • Physician Outreach
  • Rx Analysis

CMS Alerts and Opinions

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MSA Referral

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ExamWorks Medicare Compliance Portal

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Call 866-MSA-FILE for assistance.