An IFMK client came to IFMK for legal counsel after receiving a recommendation from an outside vendor to fund a Medicare Set-aside Arrangement (MSA), stemming from a series of Workers’ Compensation claims going back to 2011. IFMK’s Medicare Secondary Payer (MSP) was able to help them locate and examine several years’ worth of medical records and reports, and get the case resolved with no MSA required.
The claimant alleged injuries to his low back, hip, and knee that occurred during two work accidents in October 2011. Although the accidents themselves were accepted as compensable, liability was denied for extensive medical treatment and lost time occurring after November 2011. In 2022, an outside vendor recommended funding a Medicare Set-aside Arrangement (MSA) of over $189,000. However, the medical treatment records showed the claimant’s original physician had released him from care in November 2011, there was no mention of any knee symptoms or injury until a year after the work accidents, and an IME in October 2012 produced opinions that the claimant’s lumbar injury had stabilized as of November 2011, his later back symptoms were caused by his morbid obesity, and the additional treatment rendered after November 2011 was not medically necessary or reasonable as a result of the work incidents. In addition, updated medical records had not been obtained since 2019.
After obtaining the missing records, the evidence showed that there was no treatment recommended for the hip and none of the claimant’s treating physicians had causally connected his knee condition (osteoarthritis) to the work accidents.
Our MSP team recommended that no funds be set aside for future medical care or Medicare-covered treatment team, citing Medicare’s own internal procedures and guidelines which provide that no MSA is necessary under certain circumstances, including where the treating physician has released the claimant from care, or where medical benefits are denied after a date certain and no benefits are paid after that date. In 2025 the Illinois Workers’ Compensation Commission approved the settlement of these cases with no MSA, but with settlement terms setting forth the factual and legal bases for excluding the MSA and any funds for future medical treatment. Our MSP Our work in this case saved our client the $189,000 MSA expense.
SUBSCRIBE to receive the latest IFMK news and other important information