If you have an allocation that is preventing settlement, you might want to call Burns White for a second opinion. We can review the file to see if a better allocation can be prepared to move your case toward resolution. Second opinions give your case another chance at settlement. They give us a chance to show you our work. And they have frequently been the first step in long term partnerships with many of our valued clients.

Even if you have an approved vendor or panel, consider giving us the opportunity to see if we can reposition your case for settlement. Sometimes an MSA is too high to settle and the vendor will not discuss revisions. Sometimes Medicare approval is not required and your allocation may need adjusted to a non-submission allocating methodology. Sometimes you may not trust the opinions of your current provider and you might want to hear someone else’s thoughts. With so much at stake, it is worth getting a second opinion. Please keep us in mind to see if we can keep settlement an active possibility.

Case Study Number 1

• Competitor MSA Amount: $403,453.20
• Burns White MSA Amount: $38,199.00
• CMS Counterproposal: $45,303.00
• Total Savings to our Client: $358,150.00

This case involved a large national Medicare Set-Aside provider which prepared an MSA of $403,453.20. We were retained by a large self-insured company to review this case for a second opinion, given the high costs assessed to the MSA. After our review, we determined the two main factors driving up the cost of the MSA were medications and a Spinal Cord Stimulator (SCS). A medical-legal review of the file materials revealed that the treating physician made no reference to a SCS. The only indicator for a SCS was from an IME doctor who mentioned it as a remote possibility. Because our legal department felt confident that CMS would give little weight to the IME doctor’s suggestions, we excluded all costs associated with a SCS. Next, a Burns White pharmaceutical review found that three drugs could be excluded due to non-coverage under Medicare Part D. After sharing our ideas with the client, we were then asked to prepare a new MSA. The amount proposed by Burns White was $38,199. CMS counterproposed our submission in the amount of $45,303, which was an increase of $7,104, but an overall savings to our client of $358,150. Burns White considers this a good result despite the approval not being made on the first submission attempt. Even though CMS countered our submission with a higher MSA amount, it was still $358,150 lower than the MSA provided by the other vendor. This case shows how being a true advocate for our clients pays off, and obtaining approval on the first pass should not necessarily be the goal in best Medicare practices.

Case Study Number 2

• Competitor MSA Amount: $903,081.37
• Burns White MS Amount: $99,485.00
• CMS Approved Amount: $99,485.00
• Total Savings to our client: $803,596.37

We were asked to prepare a second opinion on a case because our client was not satisfied with the MSA that was prepared by a vendor. The first MSA came in at $903,081.37. There was a large amount of treatment in the MSA that should not have been included due to coverage issues. Specifically, the original MSA included costs for home health care that were not covered by Medicare. As some home health care is Medicare-covered and some is not, our medical-legal team carefully reviewed appropriate Medicare coverage allowances and applied those amounts to the MSA. Coverage exclusions were carefully identified and the appropriate references were included as support. We were able to combine our legal and medical experience to prepare a new MSA for $99,485, which was a reduction of $803,595.37. CMS recently approved this MSA, which provided a saving to our client of more than three quarters of a million dollars.