Seeking CMS Approval of Your MSA

Before describing how Cattie & Gonzalez helps parties seek review and approval of their MSA by CMS, it's important to understand the following: asking Medicare to approve your MSA is always voluntary. It's only mandatory when the settling parties have made this step a condition of settlement. Cattie & Gonzalez believes maintaining control of the case is of the utmost concern, and does not recommend seeking CMS approval of your MSA unless you are prepared for CMS to disagree with your MSA. That goes regardless of the partner you choose to aid in seeking CMS review of your MSA.

The purpose of seeking CMS approval of your MSA is to ensure that Medicare agrees with your MSA. You don't want Medicare coming back at a later date seeking additional money for future medical expenses. Your goal is to obtain that seal of approval from Medicare. However, the downside is that CMS disagrees with your MSA, and issues a counter-higher letter. That counter-higher letter will contain an MSA figure higher than what you submit, perhaps by 6 or 7 figures (depending on the case).

Instead of opening yourself up to the potential of a CMS counter-higher letter, you might consider an alternative risk management technique: the Cattie & Gonzalez MSA Legal Opinion. The MSA Legal Opinion accomplishes the same as a CMS-approved MSA in that clients obtaining that legal opinion for the file may rely on its conclusions going forward. Like obtaining legal advice in any other context, you have the right to rely on legal advice in the MSA context, and the MSA Legal Opinion provides that. For more information, please click here.

OK, we're happy to help. We are able to submit our own MSA Allocation or one you obtained from someone else. Importantly, CMS will recognize one and only one representative at a time when it comes to reviewing MSAs. The first one to the CMS window, in effect, can lock out the other side. If you do choose to seek CMS review and approval of your MSA, you should maintain as much control of that process as possible. Working with Cattie & Gonzalez to get your MSA approved by CMS accomplishes that goal.

In the past, Medicare did not offer any appeals process. You were stuck with the result. It's a very different scenario these days.

CMS offers re-reviews and amended reviews under certain circumstances. You may have a right to an immediate re-review if CMS made an obvious mathematical error or did not consider certain documentation dated prior to the initial submission date. You may have a right to an amended review if your case meets the following criteria:  

1) CMS has issued a conditional approval/approved amount at least 12 but no more than 72 months prior;

2) The case has not yet settled as of the date of the request for re-review; and 

3) Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount. 

Cattie & Gonzalez's experience extends to the CMS re-review and amended review process. Our combination of clinical and legal experience can best position a client's case for re-review or amended review, giving them the best chance for CMS to approve their MSA on the second go-around.