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FAQ

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Frequently Asked Questions (FAQ)

PlanPoint | Medicare Secondary Payer Act Compliance

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1. What is the Medicare Secondary Payer (MSP) Act, and why does it matter?

The MSP Act is a federal law that prohibits Medicare from paying for medical services when another party—such as a workers’ compensation, liability, or no-fault insurer—is responsible. It affects settlements, judgments, and awards by requiring proper allocation and reporting to ensure Medicare is not billed for injury-related care that should be covered by a primary payer. Failing to comply can lead to penalties, reimbursement demands, and delays in settlement.

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2. Who is responsible for MSP compliance in a personal injury or workers’ compensation case?

All parties involved—plaintiff attorneys, defense counsel, insurers, and self-insured entities—share responsibility. CMS holds all stakeholders accountable for ensuring Medicare’s interests are protected both during and after settlement. PlanPoint helps streamline this responsibility through accurate, case-specific reporting and advisory services.

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3. What services does PlanPoint provide under MSP compliance?

PlanPoint offers:

  • Medicare Set-Aside (MSA) Allocations

  • Zero-Dollar MSA Justifications

  • Conditional Payment Reviews and Disputes

  • Medical Cost Projections (MCPs)

  • Section 111 Reporting Guidance and Agent Services

Each service is delivered on a case-by-case basis, with expert review and documentation tailored to support settlement, negotiation, and regulatory compliance.

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4. What is a Medicare Set-Aside (MSA), and when is it required?

An MSA is a financial allocation set aside from a settlement to pay for future Medicare-covered medical expenses related to the injury. While not always required by law, CMS expects parties to consider Medicare’s future interests in settlements involving current or potential beneficiaries. PlanPoint helps determine when an MSA is advisable and how much to allocate, based on medical records, treatment trends, and CMS policy.

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5. Does CMS still review and approve MSAs?

CMS continues to review MSAs for workers’ compensation settlements that meet specific thresholds. However, CMS will discontinue review of Zero-Dollar MSAs as of July 17, 2025. PlanPoint provides defensible documentation and justifications to protect clients regardless of CMS review availability.

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6. What are Conditional Payments, and how do they impact settlement?

Conditional payments are medical costs that Medicare has paid on behalf of a beneficiary that are later determined to be the responsibility of another party. These must be reimbursed. PlanPoint identifies, reviews, and disputes conditional payments to ensure accurate settlement accounting and avoid post-settlement recovery demands.

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7. What is Section 111 Reporting, and do I need to do it?

Section 111 of the MSP Act requires insurers and self-insured entities to report claim information to CMS when a Medicare beneficiary is involved. Failure to report—or reporting inaccurate data—can result in civil monetary penalties of up to $1,000 per day, per claim. PlanPoint offers both guidance and full-service reporting as an Authorized Reporting Agent.

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8. Can I rely on PlanPoint’s reports for litigation or CMS inquiries?

Yes. PlanPoint reports are prepared with litigation strategy and regulatory scrutiny in mind. Each report is meticulously documented, citing medical records, case facts, and CMS policy. They are routinely used to support negotiation, satisfy CMS expectations, and defend settlement positions.

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9. How is PlanPoint different from other compliance providers?

PlanPoint does not offer one-size-fits-all or automated services. Our team specializes in complex, high-stakes cases, providing detailed, hands-on analysis tailored to each claim. We work with attorneys and insurers—not around them—ensuring our work complements your strategy and reduces post-settlement exposure.

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10. What information do I need to provide to start a report?

You’ll need basic claim details, relevant medical records, and the current settlement posture. PlanPoint provides a secure intake process and personalized support to streamline submissions and reduce your administrative burden.

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11. Does PlanPoint handle services nationwide?

Yes. PlanPoint supports clients across the United States and ensures compliance with federal MSP regulations regardless of jurisdiction.

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12. How do I get started?

Simply contact us or submit a request. A specialist will follow up to confirm details and guide you through next steps. No subscriptions. No commitments. Just focused, expert support—case by case.​​​

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