Tower MSA Partners will Present 2x at WCI

May 31, 2019

WCI Logo

WCI comes a little earlier this year (August 11-14), so make plans to attend now. Tower will present in two back-to-back sessions on August 14. Starting at 9 a.m., “Optimizing Settlement Outcomes by Measuring and Managing MSA Costs” stresses the importance of determining which metrics to use and how to use them to evaluate and improve your MSA program. Moderated by Michael Stack, CEO of AMAXX, the session features American Airline’s Kris Sallee and Tower’s Chief Compliance Officer Dan Anders who will also describe how clinical interventions produce MSAs that balance care, cost, and compliance.

Then, at 10 a.m., “Allaying the MSA Fear at Time of Settlement” examines reasons employers and injured workers avoid settling claims. Employers anticipate the MSA cost will be too high; injured workers worry that the funds will be too low, or they won’t be able to properly administer the MSA. Marques Torbert, CEO of the professional administration firm Ametros, and Joe Bornstein, a structured settlement consultant with Arcadia Settlements Group, join Kris, Dan, and Michael in a lively discussion of these challenges and their solutions and share case studies that resulted in a win-win for the employer and the injured worker.

For more information and to register for the conference, see https://www.wci360.com/conference/

Lead, Not Follow Approach Yields Compliant & Cost-Effective MSAs

May 9, 2019

paper ships - many white ships, one blue one with a flag to illustrate leadership for cost effective msa

Just like all of us, CMS makes occasional errors. Believe it or not, the government is not infallible! To protect our clients from unnecessary allocation costs, Tower takes a “lead, not follow” approach to deliver Medicare-compliant MSAs that are not overfunded. This means that we don’t just follow CMS’s rules to prepare and submit MSAs, we take the initiative to make sure CMS follows its own rules.

 

Tower challenges a CMS MSA counter-higher when our clinical and legal review produces a basis for a re-review request (a form of post-determination appeal). We typically submit re-review requests within 48 hours of receipt of the counter-higher and CMS responds in less than 14 days. Our challenges have yielded a 71% success rate and saved our clients hundreds of thousands of dollars.

 

As the following examples from the past six months demonstrate–whether its $2,000 or $200,000–Tower will dispute CMS’s calculations when we believe they are in error:

 

Miscalculated surgical pricing

CMS increased the cost of a knee replacement by $8,769. Tower submitted a re-review and stated CMS had incorrectly used the state fee schedule in calculating the surgical cost. After two re-reviews, CMS corrected the pricing to the proposed amount.

 

Addition of discontinued medication

CMS added a medication, Etodolac, that, per the medical records, had been replaced with another medication, Ibuprofen. Tower referenced the submitted medical records and Rx history on re-review and CMS agreed to remove the medication from the MSA for a $16,704 reduction.

 

Medication allocated at the wrong frequency

CMS increased the refill schedule of Tylenol #4 from every three months to monthly, increasing the MSA by $8,650. Tower submitted a re-review and cited the prescription payment history as confirming “as needed” use of the medication. CMS agreed and returned the MSA to the originally proposed amount.

 

Non-Medicare covered medication added

CMS added the medication Lyrica to the MSA resulting in a $205,658 increase in the allocation. Tower argued that Medicare coverage guidelines did not provide a basis for inclusion of Lyrica for treatment of a foot crush injury. After a re-review and escalating to CMS senior management, CMS agreed and removed the Lyrica from the MSA.

 

Treatment unrelated to the WC injury

CMS added left hip x-rays and MRIs even though the hip was not accepted on the WC claim. Tower disputed the tests’ inclusion and CMS agreed to remove, thus lowering the MSA by $2,657.

 

Miscalculated Rx pricing

CMS modified the pricing of Morphine Sulfate resulting in a $12,376 increase to the MSA. Tower advised CMS that it had used the incorrect NDC code to price the medication at $1.50 per unit versus the correct $0.73. CMS acknowledged the error and corrected.

 

Key Takeaways

The good news is that the above errors occur in the minority of MSA submissions. Most of the time CMS gets it right. However, when errors occur, Tower quickly identifies and submits a re-review request to CMS. And, in most cases, our re-review requests yield a cost-savings MSA that is Medicare-compliant. This is another way Tower delivers on its promise of Compliance by the book, closure by the numbers.

 

Business Insurance Article on CAT Claims Features Dan Anders

May 8, 2019

Business Insurance’s Angela Childers turned to Tower’s Dan Anders for insight into how claims become catastrophic. Brand-name medications, opioids and the meds required to treat their side effects, and ineffective initial treatment are among the causes he cites. Payers can prevent cost escalation by having a “settlement mindset” from the beginning, he advises. Read more here. (registration or subscription will be required.)

Tower’s Average MSA Amount Dropped by 13%

May 3, 2019

Dan Anders shared Tower’s experience on a possible trend to shift drug spend to ancillary services and alternative treatment (like acupuncture) and any effect on MSAs with WorkCompCentral’s Elaine Goodman. While another company said its average MSA amount was up 5.1% in 2018, Tower’s data shows a 13% decline in the average CMS-approved MSA. This is mainly due to reductions in prescription drugs, Anders said. And, although 66% of Tower’s MSAs were approved with no pharmacy allocation, Tower has not seen an increased allocation for non-pharmacy treatment. See more (subscription required) here.