Tower MSA Partners Selects Patricia Smith as EVP, Clinical Operations

Patricia Smith, RN, BSN, MSCC, CDMS, CLCP has joined Tower MSA Partners as executive vice president of Clinical Operations. In this role, Smith reviews and monitors clinical trends related to Medicare coverage criteria within the confines of Medicare Secondary Payer compliance, develops clinical strategies to support company’s pre- and post-Medicare Set-Aside intervention workflow and manages all clinical and pharmaceutical oversight teams.

Most recently Smith served as senior vice president of Clinical Solutions Services for Examworks Clinical Solutions. In previous positions with MedAllocators, Concentra Integrated Services, Coventry Workers Compensation, and NuQuest Resources, she produced Medicare Set-Asides, Medical Cost Projections, and Life Care Plans.

“Pat has been involved with MSP compliance and MSAs in work comp for more than 14 years,” said Tower CEO Rita Wilson. “Her clinical expertise, track record of innovation and results-driven management philosophy make her a perfect fit to lead Tower’s clinically driven model to optimize the MSA and settlement.”

A graduate of the University of Maine with a bachelor’s of science degree in nursing, Smith holds several professional credentials. She is a Medicare Set Aside Consultant Certified (MSCC), a Certified Disability Management Specialist (CDMS), a Certified Life Care Planner (CLCP), and a legal nurse consultant. She is also a member of the National Alliance of Medicare Set Aside Professionals and International Association of Rehabilitation Professionals.

Tower MSA Partners CEO, Rita Wilson, Elected NAMSAP Treasurer

Tower MSA Partners CEO, Rita Wilson, who is a board member of the National Alliance of Medicare Set-Aside Professionals (NAMSAP), has been elected Treasurer of the organization. Full details on her election as well as the election of other board members to leadership positions is detailed in the following NAMSAP new release:

ELMHURST, Ill.–(February 2, 2017)–The board of directors of the National Alliance for Medicare Set-Aside Professionals has elected the following officers for 2017:

  • President: Shawn Deane, JD, MEd, MSCC, CMSP – assistant vice president of Product Development of ISO Claims Partners
  • Vice President: Greg Gitter, CMSP – president of Legacy Claims Solutions, Inc. (a Gitter Company)
  • Treasurer: Rita M. Wilson – CEO of Tower MSA Partners
  • Secretary: Christine Melancon, RN, CCM, MSCC, CNLCP, CMSP – vice president of Operations for EZ-MSA Services

“I am honored to be selected to represent NAMSAP as president,” said Deane. “We will build upon initiatives launched by last year’s outstanding President, Gary Patureau, and forge new opportunities to improve Medicare Secondary Payer services.”

Addressing the opioid epidemic remains a top priority, and NAMSAP will continue its efforts to persuade the Centers for Medicare and Medicaid Services (CMS) to follow its own Part D guidelines when reviewing and approving Workers’ Compensation Medicare Set-Asides (WCMSAs). NAMSAP will also monitor CMS’ selection of a new Workers’ Compensation Review Contractor and the evolution of the Commercial Recovery Center.

“Promoting payer participation in NAMSAP is another high priority,” Deane added. “We are delighted to add Beth Hostetler with Albertsons and Safeway to our board of directors and look forward to better representing the MSP goals for both payers and submitters.”

Other new board members are Amy Bilton with Nyhan Bambrick Kinzie & Lowry and Monica Williams, MWC Associates.

About NAMSAP

The National Alliance of Medicare Set-Aside Professionals (NAMSAP) is the only non-profit association exclusively addressing the issues and challenges of the Medicare Secondary Payer Statute and its impact on workers’ compensation and liability settlements. Through the voluntary efforts of our members, NAMSAP is a forum for the exchange of ideas and is a leading resource for information and news in this constantly evolving area of practice. The collective knowledge of our members and NAMSAP’s resources will provide attorneys, nurses, settlement planners, claims professionals, and others with the ingredients essential to their success.

Workcompcentral Highlights Tower MSA CEO Rita Wilson’s “Edge” in MSP Compliance Technology

Tower MSA Partners CEO, Rita Wilson, is the subject of a recent Workcompcentral article, Focus on Tech Has Guided MSP Compliance Co. CEOs Career, highlighting how Rita’s career in building better pharmaceutical and worker’s compensation technology systems led her to develop a Medicare Secondary Payer (MSP) technology platform which electronically integrates medical and cost-containment information.

In discussing why the MSP compliance technology platform is a difference maker for Tower MSA, Workcompcentral’s Emily Brill quotes Rita:

Tower MSA has differentiated itself by building out a software system that monitors and shares claim information from beginning to end, integrating medical and cost containment information for “continuity” and to avoid “reinventing the wheel” by scrambling to get information from separate sources.

The article further quotes Rita in explaining how the platform assists Tower MSA in providing MSP compliance services to its clients:

Our technology platform is able to track claim information all the way through, through the conditional payment research process, through the intervention process, through the MSA process. What we did was integrate this information and track it with one software application that allows us to measure the progress each month, and determine when the right time to finalize the MSA.

In understanding the benefits of Rita’s focus on technology in MSP compliance, Ms. Brill spoke to Ann Schnure, the former Vice-President of Risk Management for Macy’s, and also a strong proponent of the use of technology in claims handling, who said of Rita:

Wilson’s focus on technology has always given the CEO an edge.

To learn more about how Tower MSA Partners’ technology platform can give you an “edge” in MSP Compliance please contact Rita Wilson at rita.wilson@towermsapartners.com or 888.331.4941.

Tower MSA Partnership with American Airlines and PRIUM Yields Legacy Claim Settlements

In a widely acclaimed presentation at the recent 2016 National Workers Compensation and Disability Conference, Jennifer Saddy, Workers’ Compensation Director for American Airlines and Mark Pew, Senior Vice President of PRIUM, detailed the successful cooperation among American, PRIUM and Tower MSA to reduce pharmacy costs, litigation referrals and Medicare Set Aside costs ultimately leading to significant claim settlements.  Tower MSA is grateful to Jennifer and Mark for highlighting how Tower MSA’s Identification, Intervention and Involvement services were a key contribution to the success of this legacy claim reduction program.
 
For more information on American’s program please read the Risk & Insurance article Make a Decision and Move the Needle: American Airlines needed to take aggressive action to resolve 6,000 lingering workers’ compensation claims.

For more information on Tower MSA’s legacy claim reduction services please contact us at 888.331.4941 or info@towermsa.com.

Selecting the Right MSP Compliance Service Provider

Shot of two colleagues shaking hands while in a meeting with colleagues in a boardroom

Please take a moment to read Michael Stack’s article outlining qualities needed in an MSP compliance partner. MSP compliance is complicated and penalties can be high. There are a lot of components – Section 111 reporting, Conditional Payments, medical and pharmaceutical interventions, legal interventions, and MSA preparation.

Typically these various activities are handled in silos, and time lags and errors can occur during the transfer to the next step. It’s easy to miss a data field or deadline.

Tower recognizes that Section 111, Conditional Payments, pre-MSA Triage, all interventions, and MSA preparation through CMS acceptance should occur in a continuous, unbroken process. That’s why we developed an all-inclusive MSP Automation Suite around compliance best practices. Our MSP Automation Suite drives the entire compliance process, automatically updates clients of each activity on the file, escalates medical and pharmacy issues, prompts for interventions and much more.

Claims close faster, quality and accuracy are assured and our clients enjoy smooth settlements. Click here for details or contact us at info@TowerMSA.com or 888-331-4941.

National Alliance for Medicare Set-Aside Professionals (NAMSAP) Names Tower MSA CEO Rita Wilson To Board

Namsap_Logo

Elmhurst, IL, January 26, 2016: On Thursday, January 21, 2015, the Board of Directors of the National Alliance for Medicare Set-Aside Professionals elected the following officers for the 2016 year:

“I am honored to have been selected by my fellow board members to represent them and our association as president,” said Patureau. “I look forward to working with our team of board members, committee chairs, management staff and all NAMSAP members to continue to strengthen our mission as the leading advocate for an efficient and effective Medicare Secondary Payer (MSP) compliance system. Following the steps of previous leaders and that of my predecessor Kim Wiswell, I am committed to promoting and growing our association, providing our members with the educational and networking opportunities they need for professional development as well as bolstering NAMSAP’s strategic goals”.

NAMSAP would like to thank Benjamin M. Basista, Esq., member of the Board of Directors since 2010 and most recently Vice President for his service to the organization. Basista is a shareholder with Dickie, McCamey & Chilcote, PC and Co-Chair of the firm’s Medicare Compliance Group, in which he concentrates his practice.

Immediate Past President Kimberly A. Wiswell, Director of Operations for MEDVAL, had this to say: “NAMSAP is a better organization thanks to Ben’s time, talent and expertise. Beyond his work on the legislative and bylaw side of the organization, Ben served as the liaison to the Membership Committee and was a consistent presence at all of our events providing his ideas, input, and enthusiasm. On behalf of the NAMSAP board we express our sincere appreciation for his service and wish him the very best in the future.”

In addition to electing officers, the NAMSAP board appointed Rita M. Wilson, CEO of Tower MSA Partners to the vacancy created by Basista’s departure. Ms. Wilson oversees all business development, sales, marketing and operational activities, IT systems development, and identifies new product offerings in support of MSP compliance. Within NAMSAP, she is Chair of the Communications Committee and a member of both the Data and Development Committee (DDC) and Evidence Based Medicine (EBM) Committee.

“Rita’s knowledge and experience in the industry as well as her commitment to NAMSAP make her an excellent addition to the overall team” said Patureau.

The National Alliance of Medicare Set-Aside Professionals (NAMSAP) is the only non-profit association exclusively addressing the issues and challenges of the Medicare Secondary Payer Statute and its impact on workers’ compensation and liability settlements. Through the voluntary efforts of our members, NAMSAP is a forum for the exchange of ideas and is a leading resource for information and news in this constantly evolving area of practice. The collective knowledge of our members and NAMSAP’s resources will provide attorneys, nurses, settlement planners, claims professionals, and others with the ingredients essential to their success.

Click here to download this press release.

Growing Press Surrounds Tower MSA’s Groundbreaking MSP Automation Suite

An article today posted by Yahoo! Finance discusses the new MSP Automation Suite by Tower MSA. The article cited the groundbreaking and sophisticated technology developed by Tower MSA that drives the MSP process.

Describing the MSP Automation Suite:

“The sophisticated technology drives all the processes Tower has perfected to proactively manage Section 111 Mandatory Insurer Reporting, the recently implemented Conditional Payment Notice process, and to stage workers’ compensation claims for Medicare Set-Asides and closure.”

Our CEO Rita Wilson offered many insights about the new MSP Automation Suite:

“Essentially, it automates our best practices for Medicare Secondary Payer compliance, claims optimization and MSA preparation.”

“Our Pre-MSA Triage identifies barriers to settlement and recommends claim-specific interventions, like physician peer review and clinical oversight, to remove those barriers long before preparing an MSA.”

“Clients don’t need to manually diary activities or call to check on things.”

“The system shows exactly when a phone call was made, and follow-up is due.”

“Automation frees claims professionals to address issues that require a human touch.”

The article went on to say:

“The MSP Automation Suite can track a claim from Medicare beneficiary identification through final settlement. It records every claim activity performed by Tower or its network of practicing physicians and pharmacists and provides clients with 24/7, end-to-end visibility into claims. The system prompts for missing data, conditional payment searches, and medical/pharmaceutical interventions and sends electronic updates to clients at appropriate data points.”

If you would like to read the full article, it is available here on Yahoo! Finance.

Tower MSA Feaured On Yahoo! Finance

An excellent article on Yahoo! Finance today features our Tower MSA Pre-MSA Triage Program.

Pre-MSA Triage
“Workers’ compensation payers using Tower MSA Partners’ Pre-MSA Triage have seen their Medicare Set-Aside allocations dramatically reduced.”

The article went on to say:

“Tower’s Pre-MSA Triage analyzes medical and pharmacy records, identifies unnecessary, inappropriate, cost-driving treatment and recommends interventions to improve patient and financial outcomes. The service ensures that MSAs include only accurate and appropriate medical and pharmaceutical allocations.”

The article also cited case studies:

“In another case, more than $210,000 of a $239,006 projected MSA was due to medication costs, including prescriptions no longer being filled. “We believed the medications were no longer necessary and should be discontinued,” Wilson said, “but without proper documentation and the correct MSA language, they would have been included in future treatment and costs.”

The full article on Yahoo! Finance is available here.

Pre-MSA Triage Works!

pills and money

Inappropriate and/or unnecessary prescription drugs, along with recommended medical procedures that are recommended, but never performed, are all too common in workers’ compensation claims. Yet they are often overlooked when moving a claim to settlement. But a new tool is helping payers identify and address obstacles, saving millions of dollars in MSA and settlement costs. Several recent cases bear out the program’s success.

Tower MSA Partners developed this unique service to ensure MSAs include only accurate and appropriate medical and pharmaceutical treatment. The Pre-MSA Triage allows payers to stage claims for optimal outcomes by providing a snapshot of MSA exposure before the MSA. By following our recommended interventions, clients are achieving CMS approval of reduced MSAs, with reductions of more than 50% in many cases.

How it works

Tower analyzes 6 months of medical records to identify care and cost issues, including the projected MSA cost of a claim based on the current medical and pharmacy treatment regimen. The review also provides a snapshot view of the MSA exposure in a non-discoverable (not an MSA) format, and offers an overview of inappropriate, unnecessary treatment and cost drivers that may impact MSA and settlement. For example, the review may uncover denied injuries and/or body parts, recommended surgical procedures that were never pursued, spinal cord stimulators that were recommended but never evaluated, gaps in treatment dates, unrelated medications, and off-label drug usage.

We then recommend various interventions, such as physician peer review, clinical oversight and conditional payment searches/negotiations to effect improved outcomes and savings in the overall claim costs, frequently as much as 50 percent!

Example Case Study

Tower’s Pre-MSA Triage projected the MSA cost for a 46-year-old male at $1,300,000. More than $1,000,000 of the total projection was due to extended prescribing of both long and short acting opioids. Tower recommended a Physician Peer Review followed by direct dialogue with the treating physician. Agreement to wean was obtained in writing and Tower initiated its clinical nurse oversight service to track progress.

Through Tower’s MSP Automation Suite, developed and maintained internally, we were able to drive the weaning process with the physician through tracked monthly calls, and to guide the adjuster as to when discontinued medications should be blocked by the client’s PBM.

Upon finalization of the weaning process, Tower worked with defense to obtain the necessary written language from the treating physician to confirm discontinuation and remove past medications. The final MSA was submitted and approved by CMS for $210,641 – a savings of more than $1,000,000 from the original estimate!

Conclusion

The example provided here is one of many success stories we are seeing, and through our MSP Automation Suite, we’ve been able to manage the process from triage through final CMS submission and approval in a secure, digital environment. Whether handled internally by our team of nurses or through a formal intervention and peer dialogue by one of our physicians, our system drives every step in the process.

Many companies can identify problems, and some even make recommendations. At Tower, we believe the key to successful MSA outcomes is a proactive approach to identify, intervene and remain involved through closure.

CMS Announces Portal Functionality for Final Conditional Payment Process

News

In its ‘What’s New’ section, CMS announced on November 9, 2015 that as part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final Conditional Payment (CP) process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.

When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP. Once calculated, this amount will remain the Final Conditional Payment Amount as long as:

The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.

How the NGHP recovery process works today

To understand the value of this announcement to simplify the final demand process, we need to revisit the recent changes in NGHP recovery and the new role of the Commercial Repayment Center (CRC).

Effective October 5, 2015, the CRC assumed responsibility for pursuing recovery directly from the applicable plan. Any recoveries initiated by the Benefits Coordination & Recovery Center (BCRC) prior to the October 2015 transition will continue to be the responsibility of the BCRC. The typical recovery case, where Medicare is pursuing recovery directly from the applicable plan, now involves the following steps:

1. Medicare is notified that the applicable plan has primary responsibility

Medicare may learn of other insurance through a Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 report or beneficiary self-report. If Medicare is notified that the applicable plan is primary to Medicare, Medicare records are updated with this information.

2. CRC searches Medicare records for claims paid by Medicare

The CRC begins identifying claims that Medicare has paid that are related to the case, based upon details about the type of incident, illness, or injury alleged. The claims search will include claims from the date of incident to the current date. If a termination date for Ongoing Responsibility for Medicals (ORM) has already been reported, the CRC will collect claims through and including the termination date.

3. CRC issues Conditional Payment Notice (CPN) to the applicable plan

The CPN provides conditional payment information. It advises the applicable plan that certain actions must be taken within 30 days of the date on the CPN or the CRC will automatically issue a demand letter. This notice includes a claims listing of all items and services that Medicare has paid that are related to the case. It also explains how to dispute any items and services that are not related to the case. A courtesy copy of the CPN is sent to the beneficiary and beneficiary’s attorney or other representative. The applicable plan’s recovery agent will also receive a copy of the CPN if the recovery agent’s information was submitted on the applicable plan’s MMSEA Section 111 report or the applicable plan has otherwise appointed a recovery agent by submitting a written authorization to the CRC.

Note: If a beneficiary or his or her attorney or other representative reports a no-fault insurance or workers’ compensation situation before the applicable plan submits a Section 111 report, the applicable plan will receive a Conditional Payment Letter (CPL). The CPL provides the same information as a CPN, but there is no specified response timeframe. When this occurs, the applicable plan is encouraged to respond to the CPL to notify the CRC if it does not have ORM and will not be reporting ORM through Section 111 reporting or if the applicable plan would like to dispute relatedness.

4. Applicable plan submits a dispute

The applicable plan has 30 days to challenge the claims included in the CPN. The applicable plan may contact the CRC or use the Medicare Secondary Payer Recovery Portal (MSPRP) to respond to the CPN.

5. CRC issues recovery demand letter advising plan of monies owed to Medicare

The demand letter advises the applicable plan of the amount of money owed to the Medicare program and requests reimbursement within 60 days of the date of the letter. A courtesy copy of the demand letter is sent to the applicable plan’s recovery agent, the beneficiary and the beneficiary’s attorney or other representative. The demand letter includes the following:

The beneficiary’s name and Medicare Health Insurance Claim Number (HICN);
Date of accident/incident;
A claims listing of all related claims paid by Medicare for which Medicare is seeking reimbursement from the applicable plan; and
The total demand amount (amount of money owed) and information on administrative appeal rights.
If the CRC agrees with disputes submitted timely, unrelated claims will be removed from the case before the demand letter is issued. Please note that the demand letter may include related claims that Medicare paid after the CPN was issued. Relatedness disputes on all claims included in the demand letter may be addressed by submitting an appeal.

6. Applicable plan submits an appeal

An applicable plan has 120 days from the date the applicable plan receives the demand letter to file an appeal. Receipt is presumed to be within 5 calendar days absent evidence to the contrary.

7. Applicable plan submits payment

If the CRC receives payment in full, it will issue a letter stating that the specified debt has been resolved. The letter will also note that new cases may be created if the applicable plan maintains ORM or the CRC receives information on additional items or services paid by Medicare during the period of ORM.

Facilitating timely and more accurate final demands

Because the CRC retains the right to create new cases as long as the applicable plan maintains ORM, timely notification of a final settlement is extremely critical to terminate the recovery efforts of the CRC. We applaud the addition of CP process functionality to the MSPRP as a segue to real time information and data exchange, and a more predictable outcome.

With more timely submissions and a published timeline for the final demand, this new extension of the SMART Act will facilitate better accuracy, a better path to closure and fewer last minute surprises…. all good things for those who represent the settlement interests workers’ compensation and liability carriers.