How AI can Help Streamline the Medicare Set-Aside Process

By Kimberly Wiswell, Director of Client Services, Embedded AI, Gradient AI

Medicare Set-Aside Arrangements (MSAs) are an important part of workers’ compensation programs and assist in earmarking settlement funds to cover future medical expenses stemming from workplace injury claims. However, providing an easy process for adjusters to refer MSAs, as well as managing operations to create these complex reports for the workers’ comp insurance industry efficiently has long been a challenge, especially when dealing with manual documentation and complex compliance requirements.

Let’s explore how the integration of AI and automation can effectively address these hurdles and make the MSA process more efficient.

Two Significant Challenges to Traditional MSA Processes Manual Documentation

The conventional MSA application process relies heavily on manual documentation. This involves the painstaking tracking of medical records, treatment history, and payment reports. This tedious approach is not only time-consuming, but also prone to inaccuracies, often requiring significant human resources. In addition, manual documentation increases the risk of missing critical information, leading to delays and potential compliance issues. Claims assistants or adjusters often spend a significant amount of time on MSA requests, ranging from an average of two to ten hours per referral, depending on factors like claim complexity, age, and the volume of medical records involved. Extended follow-up correspondence for clarification of body parts accepted under the claim or missing records can further extend this time.

Complex Regulatory Landscape

Another significant challenge is the navigation of the complex regulatory landscape of Medicare compliance. To be successful, the MSA application process requires meticulous attention to detail and expertise in interpreting Medicare's guidelines and regulations. Compliance errors can lead to penalties, delays in MSA approval by CMS, and heightened administrative burdens for all involved stakeholders.

Addressing These Challenges: Harnessing AI for Enhanced MSA Operations

AI-powered solutions can address both of these obstacles. By automating the documentation process, AI significantly reduces the manual effort needed to produce MSA determinations. Advanced algorithms can quickly analyze medical records, treatment histories, and billing information to generate comprehensive MSA documentation accurately. By automating repetitive tasks, AI reduces the likelihood of errors, accelerates processing times, and frees up resources for more strategic activities. In addition, AI technologies offer sophisticated compliance management capabilities, which allows all parties to navigate Medicare regulations with ease. AI-powered platforms continuously monitor changes in Medicare policies, ensuring MSA documentation remains up-to-date and compliant.

Additionally, AI algorithms can identify potential compliance issues proactively, allowing stakeholders to address them promptly and mitigate risks effectively. Integrating AI technologies into MSA operations can significantly impact MSA workflows. By automating the information and documentation collection and simplifying compliance management, AI streamlines both the MSA referral process, as well as internal operations, improving efficiency, and ensuring adherence to Medicare regulations. As the complexity of modern healthcare continues to evolve, leveraging AI becomes increasingly important for optimizing MSA processes and achieving better outcomes for all involved.

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