The Crystal Ball: Using Medical Investigation to Predict Future Medical Exposure

June 2018

By Marina Takagi

With cases involving complicated medical issues, the idea of shutting down medical rights due to potential future medical exposure seems daunting and unpredictable. However, with thorough medical investigation, BCM’s Medicare Compliance Department is able to foresee potential exposure for a Medicare Set-Aside Arrangement (MSA), and recommend the best legal course of action to resolve the claim.

In such a case, the petitioner was a younger employee that alleged exposure to chemicals in the workplace. This was the beginning of the petitioner’s extensive treatment for scleroderma, Raynaud’s syndrome, pulmonary fibrosis, and systemic sclerosis. Ultimately, the petitioner underwent a lung transplant. Following the transplant, the petitioner continued treatment required to avoid transplant rejection, as well as treatment to combat numerous infections.

In evaluating this fact pattern, most would be leery about the potential future medical exposure involved with an MSA. However, in order to move the case forward and reach a potential agreement, an evaluation for future medical care was necessary, especially given the petitioner’s numerous infections, failing health, and continued hospital stays. Open medical rights could have involved extensive and expensive treatment, given the medical history. The BCM Medicare Compliance Department prepared an MSA proposal of approximately $150,000.00 that was eventually submitted to the Centers for Medicare and Medicaid Services (CMS) for review. The proposal included future physician’s visits, pulmonary rehabilitation, intermittent diagnostic testing, blood testing, anti-rejection medications, and anti-infection medications. Although the petitioner underwent extensive medical treatment for the lung transplant, detailed medical investigations as well as evaluating the petitioner’s medical history and pharmacy history, allowed BCM to prepare a realistic MSA proposal, specific to the petitioner’s treatment plan. CMS approved BCM’s exact proposal. By calculating the MSA amount and strictly limiting it to actual medical evidence, the results enabled further potential settlement negotiations to close out not only future medical exposure, but the entire case. In the end, even when future medical seems daunting, BCM’s Medicare Compliance Department can help to accurately predict potential exposure and allow for potential closure of age-old cases.