Medicare Compliance

The Proven
Medicare Advantage

ExamWorks Clinical Solutions (ECS) provides clients with access to an all-inclusive portfolio of Medicare compliance solutions, including Workers’ Compensation and Liability Medicare Set-Asides, Lien/Conditional Payment Resolution and related services that reduce costs and promote compliance. Our full scope of integrated processes and settlement planning services are focused on business goals while keeping clients informed, prepared and equipped to avoid costly issues.


ExamWorks Clinical Solutions (ECS) utilizes knowledge and expertise to provide Medicare Compliance services determining a reasonable allocation of injury-related Medicare-covered medical expenses projected over the claimant's life expectancy. A portion of the settlement is then allocated to the Medicare Set-Aside (MSA) in either Workers' Compensation or Liability cases. The allocation ensures that the burden of future injury-related medical care is not shifted to Medicare as a result of a settlement. When necessary, a Prescription and Treatment Addendum to the MSA report is prepared, which empowers the adjuster with the knowledge and documentation to contain and often limit the MSA amount.

Read More

The ECS Addendum is a unique tool that advises the adjuster of issues identified from our review of the file that may result in an increase to the MSA amount upon approval (counter-higher). Each Addendum provides clear and concise recommendations for documentation that should be obtained and actions that can be taken to avoid a counter-higher. Consequently, the adjuster can choose to obtain the recommended documentation themselves or refer to our Solutions Center.

ECS offers an aggressive approach to calculating the MSA amount utilizing medical documentation and recognized standards of care criteria to appropriately consider Medicare's interests and obtain CMS approval.

  • Allocation figures are produced by our team of in-house compliance experts, pharmacists and Planners who are registered nurses with Life Care Planning credentials and Medicare Set-Aside Consultant Certified (MSCC) designations
  • Our staff is comprised of subject matter experts who demonstrate and are capable of defending the adequate consideration of Medicare’s future interest for all types of claims
  • Our expertise allows you to submit the MSA to CMS for review and approval, while solidly protecting Medicare’s interests
  • Our experienced and proven staff of compliance experts can assist you with a simple and efficient resolution of MSP concerns for Mass Tort claims, saving you time and money

Medicare Liens /
Conditional Payment Services

The first step in the CMS submission process is the completion of an MSA. Our Medicare Lien/Conditional Payment services help clients navigate the Medicare system to secure the approval of settlements by the Center for Medicare & Medicare Services (CMS) in a timely manner. 

It is essential that any Medicare Liens/Conditional Payments are discovered and resolved prior to settlement. Our Medicare Lien/Conditional Payment services work as the connection between the beneficiary and CMS or attorney to establish the Medicare reimbursement amount and whether it is justified. We work to reduce the amount needed to resolve the claim.

Read More

Through our Medicare Lien/Conditional Payment services, we:

    • Perform research to identify Conditional Payments due Medicare
    • Determine if there are liens due to a Medicare Advantage Plan (MAP) and may be the responsibility of the carrier/insured
    • Research and negotiate for Medicaid according to the state specific formulas

Our conditional payment negotiations results show that, on average, we reduce the Conditional Payment Research significantly from the original demand amount.

Medical Cost Projection

The Medical Cost Projection (MCP) provides a comprehensive and cost-effective solution to forecast future medical exposure and establish an accurate basis upon which to set reserves and identify cost drivers for Workers’ Compensation claims and Liability files. By accurately projecting future medical exposure, our MCP service becomes an invaluable negotiation tool for mediation and settlement.

Read More

The Medical Cost Projection furnishes customers with an expert medical projection necessary to proactively position the claim for resolution. A Medical Cost Projection identifies areas to be addressed and potential cost savings associated with each recommendation. It is a timely and cost-effective tool for reserve setting to assist in settlement negotiations. Also included in the Medical Cost Projection are detailed future medical, prescription drug, and durable medical equipment needs for the individual’s life expectancy.

Life Care Plan

The ExamWorks Clinical Solutions Life Care Plan – a dynamic document based on published standards of practice, comprehensive assessment and data analysis/research – provides a projection of medical expenses and contingencies related to an injury. The values for each future care recommendation are itemized, researched and documented according to standard Life Care Planning methodology, as defined by the International Academy of Life Care Planners. Our Life Care Planners have the qualifications and knowledge required to defend the reports if litigation is necessary.

Read More

Our Life Care Plans are prepared by Certified Life Care Planners who interact with the treating physician(s), injured workers, and treatment teams to provide the most current and appropriate recommendations. Life Care Planners present your financial analysis in an easy-to-read document that clearly establishes total lifetime medical and associated costs.

Legal Nurse Review

We recommend a Legal Nurse Review for cases that may require litigation. The comprehensive report targets medical and cost-containment information and includes a complete chronology of medical documentation provided in a narrative format with case-specific recommendations.

Services include, but are not limited, to:

  • Identifying and determining damages and related costs of services, including collaborating with economists in preparing a cost analysis for damages
  • Conducting client interviews, researching and summarizing medical literature
  • Identifying and applying multi-disciplinary standards of care and regulatory requirements
  • Preparing chronologies of medical events and comparing and correlating them to the allegations
  • Educating attorneys regarding medical facts and issues relevant to the case
  • Developing future medical cost projections
  • Detecting medical tampering, late entries, inconsistencies, omitted records and conflicting information in the medical records


ECS provides Medicare Set-Aside (MSA) resolution services, complex claim management recommendations, clinical negotiation services and resource coordination. Our nurses have Life Care Planning credentials and MSCC certification and work in conjunction with our case management and Medicare compliance experts, offering an integrated complex claim and pharmaceutical solution. Contact us to learn more about the commitment, investment and applications.