Selecting the Right MSP Compliance Service Provider

June 30, 2016

Please take a moment to read Michael Stack’s article outlining qualities needed in selecting the right MSP compliance service provider.. Medicare Secondary Payer 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 Medicare Set Aside (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.

In his article, Stack notes that:

“Effective MSP compliance includes a service provider that goes beyond the basics. These providers will offer services that allow members of the claim management team to focus on their job and provide information and resources to comply with Medicare regulations in workers’ compensation claims.”

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. To learn more, contact us at info@TowerMSA.com or 888-331-4941.

 

Related posts on compliance:

Tower’s Medicare Secondary Payer (MSP) Compliance Countdown

The Year in MSP Compliance (2019)

How Do You Know Your MSP Compliance Data is Secure?

 

Opioids in the Life of the MSA… Coming Soon

June 10, 2016

In a statement released on June 7, 2016, the National Alliance of Medicare Set-Aside Professionals (NAMSAP) announced the 2nd in a series of webinars focused on opioid drugs in the Medicare Set Aside.  The release can be found at NAMSAP Presents “Opioids in the Life of the MSA” Webinar on June 21

 Background

Since the creation of NAMSAP’s Evidence Based Medicine Committee in 2014, opioid use has been in the forefront of attention within NAMSAP.  As a member of NAMSAP’s Board of Directors, I have participated in our organization’s efforts to collaborate with experts on this critical issue, to educate our members as to what is happening when opioid involved MSAs are reviewed by CMS, and now to advocate to entities outside of workers’ compensation.

Our goal is to publicize the conflict between the WCMSA review process and  CMS’s own criteria for opioid addiction triggers, prior authorization requirements and mandatory weaning.   This release explains the rationale and basis for our request: NAMSAP has called for CMS to limit opioids in the MSA review;

The easy answer

Many say the answer to the inconsistencies in the WCMSA review process as it relates to opioids is to stop submitting the MSA to CMS.  “Why feed into a broken system?” is the question I’ve heard.  If opioids aren’t appropriate for life expectancy, if addiction is imminent, if weaning is appropriate, then include this in the MSA and just don’t submit.

I absolutely endorse CMS non-submission as an option.  Where I may differ from others is that I believe it should be decided based on the facts of the case as compared to the objective and subjective nature of CMS’s review and approval process.  Unfortunately, I fear a corporate non-submit strategy is a slippery slope down the path of massaging the MSA to ‘fit’ the needs of the moment.  That is not its intent of the MSA, nor will it be left unchallenged in the long term.

What if?

I believe the prevalence of opioids in workers’ compensation indicates something is broken, but the break is much further up the food chain.  Can and should CMS ‘fix’ a problem that we have allowed and enabled over the life of the claim?  Can an excise tax on opioids fix the problem?

What if we looked at things differently?

  • What if we identify the physicians who don’t write for opioids as first line treatment for pain?
  •  What if we know and use the physicians with a proven track record of getting patients back to work
  •  What if we implement triggers to identify initial onset and changes in opioid dosage and frequency?
  • What if an increase in Morphine Equivalent Dosage was measured and addressed immediately with the physician?
  •  What if we leverage PBM reports and tools to block opioids based  on corporate designated criteria, and then execute an action plan?
  •  What if we use jurisdictional options like UR, IMR, challenging treatment to force dispute resolution and state options to allow the carrier to control physician choice where these options exist?

What if?

Working both sides

Every company has its own strategies to address the opioid issue.  Our policy at Tower is to ask every ‘what if‘ question possible as we work with clients throughout the claim and settlement process.  Whatever the answer, whether it’s physician follow up to track weaning, a formal physician peer review to challenge inappropriate treatment, or negotiating a Conditional Payment Notice to dissociate unrelated treatment, our MSP Automation Suite drives and tracks every step in the process.  We push the claim to optimize outcomes and acknowledge when the MSA is ‘ready‘ to submit.

The result of the combined efforts of all stakeholders in workers’ compensation, according the WCRI report on opioids released on June 9, 2016 is that the industry has made positive strides to address opioid issues.  Now NAMSAP is challenging CMS to modify the WCMSA review criteria so that it more closely mirrors its own Part D approvals process.

I hope you will join the webinar as we look at the policy side of the opioid issue within the MSA and that you join our advocacy efforts.

 

CMS to ‘Consider’ Expanding Its Review Process to Include Liability MSAs

In a News Alert released Thursday, June 9, 2016, the Centers for Medicare and Medicaid Services (CMS) announced is considering expanding its voluntary Medicare Set-Aside Arrangements (MSA) amount review process to include the review of proposed liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS plans to work closely with the stakeholder community to identify how best to implement this potential expansion. CMS will provide future announcements of the proposal and expects to schedule town hall  meetings later this year.

The link to the alert can be found in the ‘What’s New’ section of the Medicare Coordination of Benefits and Recovery Overview page at CMS.gov.

https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Whats-New/Whats-New.html

Background

Signed in June, 1980,

42 U.S.C. §1395y(2)(A)) prohibits Medicare from making payment, except as provided in (B), for any item or service, to the extent that payment has been made, or can reasonably be expected to be made, under a workers’ compensation law or plan, an automobile or liability insurance policy or plan (including a self-insured plan), or no fault insurance.

42 U.S.C. §1395y(2)(B) – The Secretary may make payment under this title with respect to an item or service if a primary plan as described in Subparagraph (A) has not made or cannot reasonably be expected to make payment with respect to such item or service promptly. Any such payment shall be conditioned on reimbursement to the appropriate Trust Fund in accordance with the succeeding provisions of this subsection.

While statutory provisions included Liability cases, there were no LMSA guidelines .  As a result, actions taken to comply with the MSPA statutes in a Liability case ranged from extremely conservative to strategies that earned the LMSA environment its characterization as ‘The Wild West’.  Those who took the conservative route followed the CMS guidelines established for WCMSA.  Other strategies ranged from making the LMSA decisions based on the severity of the injury in a liability case to doing nothing.

CMS’s Review of LMSAs

With no established thresholds for CMS submission and review, those who took the conservative path followed WCMSA guidance and attempted to submit.  While certain of the CMS offices would review an LMSA, acceptance was random.  Eventually, with greater acceptance and use of the WCMSA portal, CMS began to reject LMSAs.  Submitters could make the effort to submit and obtain a letter of rejection.

While not a ‘safe harbor’, the attempt to submit was at least evidence of efforts to follow the guidelines.

CMS’s first attempt to address LMSAs

In June 2012, CMS began the process by releasing an Advanced Notice of Proposed Rulemaking (CMS-6047-ANPRM) to solicit public comment on how to implement an MSP process for liability settlements.  The ANPRM received many public comments.

On August 1, 2013, CMS sent the NPRM to the OMB for their approval.  The NPRM was never made public because the OMB did not approve it, and on 10/8/2014, this last attempt at  ‘guidance’ surrounding Liability MSAs faded into the sunset whenCMS withdrew the NPRM.   The reasons for the OMB’s rejection of the proposal were never made public.

Where are we now?

With the Liability TPOC mandatory reporting threshold of $1,000 beginning January 1, 2015 (and the voluntary threshold of $300), the BCRC now has access to more data on Liability claims than ever.  And with the announcement of the CRC (Commercial Repayment Center) in October, 2015, and its singular focus on payer recovery, the BCRC has greater resources to pursue recovery with Liability settlements.  With this combination of information and resources, it would follow that the absence of documented evidence to show that Medicare’s interests have been considered when settling a liability claim might lead to financial exposure for all stakeholders in the process…. the perfect time to introduce ‘guidance’ for the LMSA.

Tower will continue to monitor associated news on this topic and will actively participate in the TownHall Meetings regarding this topic.