Carriers and claimants can take several steps to ensure both compliance with CMS and to obtain the most favorable outcomes.

Case Management – It is essential that medical documents do not reflect inflated treatment, and that questionable costs are rationalized. Additionally, if a physician makes a recommendation for a treatment or medication that the claimant never receives, it is important that he notes in the file that it is no longer recommended or a part of the treatment.
Reallocate Old Files – If you have already received an MSA and it is over six months old, it should be reviewed by the allocator. There have been so many policy changes at CMS that it is worthwhile for the allocation to be reviewed and refreshed prior to submission.
Do not submit non-threshold files – Where previously CMS would issue a "Declined to Review" letter on files that were below the work-load review thresholds, more often it is now reviewing these MSAs and responding back with large counter-higher decisions.
Incorporate the physician – As indicated above, ask often about the plan for treatment. The opinions of treating physicians are appropriately held in high regard by CMS, so it is important that they are very clear about the plan for future treatment.
Ensure that the prescription provider you work with will provide a prescription pay history. Medicare will almost always require these to process CMS submissions.
Be clear about any denied conditions and do not make any payments relative to anything unrelated to the compensable injury. CMS views payment as acceptance of that condition.
Work with an MSA vendor that utilizes both attorneys and a medical staff to ensure that your MSA is sound both legally and medically.
If your preference is to settle prior to a CMS decision, do not do so without clear settlement language regarding who will be covering any overage that results from a CMS counter-higher decision.

Finally, while there is no formal appeals process for CMS decisions, it is important to know that in many situations CMS will re-review decisions and issue a revised decision where appropriate. It is imperative that carriers partner with an MSA provider that understands the impact CMS decisions have on the settlement process. A qualified MSA provider will be able to review CMS decisions to make certain that every possible step is taken to ensure that the appropriate amount of funds are set aside.

Special Reports /

Who Wants to Settle? The Impact of CMS' Prescription Policy on Settlements

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