Frequently Asked Questions
Workers' compensation case management and Medicare Set-Aside answers.
Case management
What does a workers' compensation case manager do?
A case manager helps coordinate the injured worker's care and communication among the worker, treating providers, employer, adjuster, and other involved parties. Depending on the claim, the work may include tracking the treatment plan, identifying delays, arranging services, and supporting a medically appropriate return to work. Case management does not replace the treating clinician's medical decisions.
What is the difference between telephonic and field case management?
Telephonic case management coordinates care remotely through calls and communication with the claim team and providers. Field case management adds in-person work when direct coordination is needed, such as a complex treatment plan, several providers, or a difficult return-to-work transition. The best fit depends on the injury, current barriers, location, and claim goals.
When should an adjuster or employer consider referring a case?
Consider a referral when recovery is not progressing as expected, appointments or treatment are delayed, the worker is moving between care settings, return-to-work restrictions are unclear, or several parties need coordinated updates. Early review can also help determine whether telephonic, field, or a more specialized service is appropriate. Case Management Solutions can discuss the claim's circumstances before a referral.
What is catastrophic case management?
Catastrophic case management is intensive coordination for serious, complex injuries that may involve hospitalization, rehabilitation, multiple specialists, equipment, family needs, and long-term planning. Case Management Solutions' CAT team provides immediate triage and multidisciplinary coordination after referral. The care plan should be tailored to the injured worker and the claim.
Do you offer vocational and bilingual case management?
Yes. Case Management Solutions offers vocational services, including transferable skills analysis, labor market surveys, and job placement support. Case Management Solutions also offers bilingual case management to reduce communication barriers among the worker, providers, and claim team. Availability and language coverage should be confirmed for the specific referral.
What information should I have ready when referring a case?
Start with the claim contact, injury and treatment summary, current providers, key dates, known barriers, work status or restrictions, and the specific help requested. Case Management Solutions can confirm any additional records, authorizations, or jurisdiction-specific information needed through its intake process. Do not send sensitive claimant information through an unapproved channel.
Medicare compliance and settlements
What is Medicare Secondary Payer (MSP) compliance?
The MSP rules address when another payer, such as workers' compensation, has payment responsibility ahead of Medicare. In a settlement, parties need to consider Medicare's interests in past and future medical expenses connected to the claim. The right workflow depends on the claim facts; Case Management Solutions offers MSA, conditional payment, and reporting-related services.
Explore Medicare compliance Centers for Medicare & Medicaid Services overview
What is a Workers' Compensation Medicare Set-Aside (WCMSA)?
A WCMSA allocates part of a workers' compensation settlement to future medical services and prescription drugs related to the work injury that Medicare would otherwise cover. The Centers for Medicare & Medicaid Services (CMS) describes it as a way to protect Medicare's interests in settlements with future medical expenses. The appropriate amount is determined from the individual claim, not a fixed percentage.
Is a WCMSA or CMS review always required?
CMS says there is no statute or regulation requiring a WCMSA proposal to be submitted to CMS for review. It recommends the review process when its criteria are met. Parties still must consider Medicare's interests when settling future medical expenses. Whether to prepare an allocation, submit it, or use another documented approach is a case-specific decision for the appropriate claims and legal professionals.
What are CMS's WCMSA review thresholds?
As of October 11, 2026, CMS says it will review a proposal when the claimant is a Medicare beneficiary and the total settlement is greater than $25,000, or when the claimant has a reasonable expectation of Medicare enrollment within 30 months and the anticipated total settlement amount is greater than $250,000. These are CMS workload review thresholds, not a statement that smaller settlements may ignore Medicare's interests. Verify the current criteria before acting because CMS may change them.
Can an MSA be zero dollars?
A zero-dollar allocation may be a case-specific conclusion, but CMS stopped accepting or reviewing zero-dollar WCMSA proposals on July 17, 2025. CMS says entities should retain documentation supporting a zero-dollar determination. A “$0 MSA approval” is not a current CMS review option.
What is the difference between an MSA and a medical cost projection?
A medical cost projection estimates likely future medical costs for planning, reserving, or settlement discussions. A WCMSA focuses on future work-injury-related expenses that Medicare would otherwise cover and is used to address Medicare's interest. Their scope and purpose differ, even when they draw on some of the same medical records.
What can delay MSA review or settlement planning?
Incomplete or outdated medical records, an unclear current treatment plan, medication lists that do not match the record, missing settlement information, and unresolved questions about future care can slow analysis. A clinical review can identify what needs clarification, while the treating provider supplies clinical documentation when appropriate. No review can guarantee a lower allocation or CMS approval.
Who manages MSA funds after settlement?
A Medicare beneficiary can self-administer a CMS-approved WCMSA or choose professional administration. Self-administration involves a separate account, tracking eligible expenses, recordkeeping, and annual attestations. A professional administrator can handle much of that work under its service terms. Case Management Solutions can discuss its post-settlement administration coordination and available partner options, and can coordinate both professional administration and self-administration services for its MSA clients, with a vision of making healthcare easy for injured individuals to manage their post-settlement funding.
Ask about post-settlement administration CMS self-administration guidance
How do I ask Case Management Solutions about a specific claim?
Use the Ask an Expert or Contact page for service questions, or Refer a Case when you are ready to begin intake. A Case Management Solutions specialist can identify the next information needed for the particular case.
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