Will CMS Still Approve Zero-Dollar MSA?

While there are strict documentation requirements, there are still three ways you can get CMS to approve a zero-dollar MSA.

1. The Claim is Fully Contested

The first scenario where CMS will approve a zero-dollar MSA is if the claim is fully contested. This does not just mean a formal contest has been filed by the Respondents. CMS requires proof that no medical or indemnity payments have been made by the Respondents. (In certain states, some medical payments can have been made during a statutory investigating period.) Payments for expenses such as an independent medical examination, case management and obtaining medical records does not prevent CMS from approving a zero-dollar MSA. In order to propose a zero-dollar MSA under this scenario, CMS requires certain documentation including a complete payment history (even if blank) showing all payments made by the Respondents from the start of the claim. The payment history must have the run date and be divided into categories for medical, indemnity and expenses with subtotals for each category and a grand total listed. This printout needs to include the print or run date. CMS recently added a requirement that there must be a proposed or agreed upon settlement in place at the time of submission. Copies of the final or draft settlement documents must be provided as part of the submission. Other documents that must be provided at the time of submission include the First Report of Injury (or a statement that one does not exists), a financial detail and denial letter that confirms the denial of the claim and any other necessary explanations, medical records from the last two years of treatment, a pharmacy printout and a Consent to Release signed by the Claimant.

2. The Treating Physician Certifies No Further Injury Related Treatment is Necessary

Even if the claim has been accepted and medical bills paid by the Respondent, CMS will approve a zero-dollar MSA if there is medical documentation indicating that no further injury-related treatment is necessary. In order to obtain a zero-dollar MSA under this scenario, you must have an opinion from the Claimant’s authorized treating physician that the Claimant will no longer require any Medicare-covered treatments related to the work injury. The opinion from the treater must be stated within a reasonable degree of medical probability. CMS will accept a statement from the treating physician that states the injury-related treatment has resolved or returned to baseline (when there was a pre-existing condition) and that no further injury-related treatment will be necessary. It is important to note that the treating physician’s statement must be consistent with the treatment records. In other words, CMS will not likely approve a zero-dollar MSA based upon a narrative report that says no further injury-related treatment is necessary where the doctor’s contemporaneous office notes reference the need for additional treatment. Additionally, CMS will not approve a zero-dollar MSA if the injured worker will require a revision to a surgery or replacement of a prosthetic. In addition to the statement from the treating physician, the submitter must provide a payment history, medical records from the last two years of treatment, a pharmacy printout and an executed Consent to Release.

3. Judicial Decision After a Hearing on the Merits

The third and final scenario where CMS will approve a zero-dollar MSA is if there is a judicial decision after a hearing on the merits. The judicial decision can involve a complete dismissal of the claim or where the judge finds all future medical treatment is unrelated to the work injury. It is important that the decision be issued after a hearing on the merits. This means that evidence must be submitted in the form of testimony and/or documentary evidence and cannot be based upon an agreement between the parties that is rubber stamped by the judge. Other documents that must be submitted to CMS include a payment history, medical records form the last two years of treatment, pharmacy printout and Consent to Release executed by the Claimant.

If you have any questions about whether your case qualifies for a zero-dollar MSA, please call us at (866) 306-9423.