Tower MSA Partners

CMS Section 111 Update: Key Changes to ORM Termination and TPOC Reporting

May 13, 2026

The Centers for Medicare and Medicaid Services (CMS) has released an update to the Section 111 NGHP User Guide (Version 8.4), introducing important clarifications related to:

Ongoing Responsibility for Medicals (ORM)
Total Payment Obligation to Claimant (TPOC) reporting
Wrongful death claims
Medicare Set-Aside (MSA) reporting in multi-defendant cases.

While many of these updates reinforce existing practices, several changes carry meaningful compliance implications for Responsible Reporting Entities (RREs).

Expanded Guidance on ORM Termination

CMS updated Chapter III, Section 6.3.2 of the Policy User Guide to clarify acceptable circumstances for terminating ORM.

The revised language states:

“Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits, or any other reason that is not prohibited by the terms of the insurance contract or applicable state or federal law.”

CMS also added:

“Note: An insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.”

What This Means

This update introduces helpful flexibility, but it does not create new substantive grounds for terminating ORM. Nonetheless, RREs may feel more comfortable with terminating ORM based on the following:

Claim denials
Independent Medical Examination (IME) results
Maximum Medical Improvement (MMI) determinations
Claimant non-compliance (e.g., refusal of treatment or IME)

In short, CMS has clarified when termination may be recognized, not expanded the legal basis for termination.

Clarification of TPOC Date in Workers’ Compensation Settlements

CMS also added a helpful example in Section 6.4 of the Policy Guide regarding the proper TPOC date to use when commission approval of a workers’ compensation case is required:

“Example: The parties to a workers’ compensation case execute an agreement regarding the claim on 01/20/2026. The state requires the workers’ compensation commission to approve the final settlement details and said approval occurs on 02/05/2026.”

According to CMS, the TPOC date is February 5, 2026, because it was the later of:

The date the agreement was fully executed
The date the court or commission approved the agreement.

What This Means

For many workers’ compensation settlements, this confirms what has already been standard industry practice: the commission approval date will be the TPOC date.

Updated Approach to Wrongful Death Claims

CMS also modified the language in Section 6.5.1.4 related to wrongful death claims.

Previously, CMS stated that wrongful death settlements were not reportable if they:

Did not claim or release medicals, and
Did not have the effect of releasing medicals

The revised language now emphasizes Medicare recovery rights and documentation.

“Note: In order for the wrongful death theory of liability to preclude Medicare from recovering from a settlement, judgment, award, or other payment, complete documentation must be provided that shows what was claimed and released or had the effect of being released. Additionally, a citation to the appropriate state statute or case law that precludes recovery from a wrongful death settlement should be included with any such dispute or appeal.

The prior language was:

Settlements, judgments, awards, or other payments entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported because Medicare would have no recovery claim against such a payment.

What This Means

It is unclear why CMS modified the language in this section, which shifts the focus from the release of medicals to recovery; however, the underlying requirements remain: a settlement is not reportable unless medicals are claimed and released as part of that settlement. This includes a wrongful death settlement.

TPOC Reporting in Multi-Defendant Cases

CMS also clarified reporting requirements for multiple settlements involving the same claimant. The updated guidance confirms that where liability is proportionate or several, but not joint and several, each RRE should report only its own TPOC amount.

CMS added the language in bold:

Multiple settlements involving the same individual – If there will be multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs (proportionate or several liability but not joint and several), the records shall reflect each RRE’s unique TPOC amount and not the aggregate TPOC the beneficiary will be receiving. If more than one RRE has assumed responsibility for ongoing medicals, Medicare would be secondary to each such entity.

Example

If:

The total settlement is $100,000, and
One RRE’s share is $25,000

Then that RRE reports a TPOC amount of $25,000 — not the full settlement amount.

What This Means

This reinforces that reporting obligations where there is not joint and several liability are entity-specific, aligning each RRE’s reporting with its actual financial responsibility and avoiding over-reporting of settlement amounts.

The update helps avoid:

Over-reporting settlement amounts
Duplicate reporting
Confusion around proportional liability scenarios

Medicare Set-Aside (MSA) Reporting Clarifications

CMS also revised guidance regarding WCMSA reporting in cases involving:

Multiple dates of injury, or
Multiple defendants

CMS updated with new information in bold:

“As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting each RRE must report the total MSA Amount—not just its assigned or proportionate share. System logic exists such that only the first reported MSA amount will be applied for purposes of coordination of benefits.”

The updated language states that where multiple RREs are reporting, each RRE must report the full MSA amount — not merely its proportionate share.

CMS further notes that system logic applies only the first reported MSA amount for coordination of benefits purposes.

What This Means

This creates a notable distinction between:

Financial responsibility, and
Reporting obligations

Even where liability is divided, all RREs are required to report the entire MSA amount, making coordination among defendants critical to ensure consistency and avoid confusion.

Example (using the scenario above)

Assume:

Total settlement = $100,000
One RRE’s share = $25,000
WCMSA amount = $50,000

The RRE would report:

TPOC Amount: $25,000
WCMSA Amount: $50,000

Because all RREs must report the full MSA amount, coordination among defendants is critical to ensure consistency and avoid reporting discrepancies.

Final Thoughts

These updates do not fundamentally change Section 111 reporting—but they do tighten expectations around documentation, consistency, and defensibility.

RREs should review internal protocols, particularly around:

ORM termination decisions
Wrongful death claim handling
Coordination in multi-defendant settlements

Small missteps in these areas can create outsized compliance risk.

If you have any questions, please reach out to Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com .

From Backlog to Breakthrough, Reducing 43 Percent of Legacy Claims

May 5, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 8 Reducing Legacy Claims

A large payer came to Tower MSA Partners with a backlog of legacy claims that had stalled for months, and in some cases years. These claims included outdated medical records, unclear treatment histories, and MSAs that had never been reviewed for accuracy. Through structured medical review and focused cleanup, Tower helped the payer resolve 43% of these legacy claims. This case reflects a broader trend in workers’ compensation, where successful legacy claim resolution depends on accurate clinical validation and updated MSA preparation.

Why Legacy Claims Stall

Legacy claims don’t linger because they are unsolvable, they stall because the underlying data is no longer accurate.

In this case:

Treatment histories no longer reflected current care
Medications included in MSAs had long been discontinued
Medical projections were based on outdated assumptions
Files had not been clinically reviewed in years

These issues led to inflated exposure, unclear settlement positions, and hesitation from all parties involved.

Turning Aging Files into Actionable Claims

Tower MSA Partners implemented a structured review process focused on clinical accuracy and defensibility.

Each claim was evaluated to:

Remove discontinued or unnecessary medications
Correct or eliminate outdated treatment projections
Align medical records with current care status
Rebuild MSAs based on actual medical necessity

Tower’s clinical team actively reconciles treatment patterns against real-world care. This ensures allocations reflect what is actually happening—not what was assumed years ago.

The result: MSAs that are accurate, defensible, and ready to support settlement.

How Collaboration Supports Legacy Claim Settlement

Updating the MSA alone is not enough—claims move when all stakeholders are aligned.

Tower worked closely with the claims team to clearly document and explain each change, giving adjusters confidence in the updated exposure. In parallel, structured settlement and professional administration partners were introduced to address claimant concerns about future medical care.

This combination helped:

Reduce claimant resistance
Eliminate uncertainty around future treatment funding
Create cleaner, more predictable submissions to CMS

Files that had been stagnant for years were now positioned for resolution.

Why Legacy Claim Resolution Makes a Difference

Without clinical validation, MSAs drift away from reality over time. They become inflated, difficult to defend, and harder to settle.

Tower’s approach restores alignment between medical documentation and actual care by:

Verifying current treatment status
Eliminating unsupported projections
Ensuring compliance with CMS expectations

This transforms legacy claims from uncertain liabilities into actionable settlement opportunities.

Results That Reflect Expertise

Through a focused legacy claim strategy:

43% of legacy claims were resolved
Previously stalled files became settlement-ready
MSAs were updated to reflect current medical reality
Submissions were supported by clear, defensible documentation

What This Means for Payers

If you have claims that have not moved in years, there is a strong likelihood they are being driven by outdated medical assumptions—not true exposure.

Correcting those assumptions can unlock significant progress without increasing settlement spend.

Ready to Move Your Legacy Claims?

Tower MSA Partners helps payers reduce backlogs, improve MSA accuracy, and accelerate settlements through clinical intervention and disciplined review.

If you’re carrying aging claims that continue to stall, it may be time to reassess what’s driving them.

Contact our team or connect with Hany Abdelsayed, Executive Vice President, Strategic Services, at hany.abdelsayed@towermsa.com to discuss your legacy claim strategy.

Frequently Asked Questions

What is legacy claim resolution?

Legacy claim resolution is the process of reviewing long-standing or stalled claims to correct outdated medical projections and prepare accurate MSAs that support settlement.

Why do legacy claims stall?

They often include outdated treatments, discontinued medications, and unclear medical histories that make MSAs inaccurate or inflated.

How does Tower reduce legacy claim backlogs?

Tower updates records, verifies treatment plans, corrects pharmacy projections, and prepares accurate MSAs supported by current documentation.

Does CMS accept updated MSAs on old claims?

Yes. CMS accepts updated allocations when the documentation accurately reflects the claimant’s current medical needs.

How long does legacy claim resolution typically take?

The timeline depends on the condition of the claim files and the level of medical review required. Many legacy claims can move toward settlement within weeks once records are updated and MSAs are corrected to reflect current medical needs.

CMS Webinar Clarifies WCMSA Reporting Rules

April 22, 2026

In an April 15, 2026, webinar, Centers for Medicare and Medicaid Services (CMS) staff discussed important clarifications that will materially impact how Workers’ Compensation Medicare Set-Asides (WCMSAs) are reported under Section 111.

Several of these comments go beyond technical guidance—they directly affect whether CMS will review a WCMSA at all, how settlements are interpreted, and how Medicare coordinates benefits post-settlement.

Below are the most important takeaways, along with what they mean in practice for payers, TPAs, and Responsible Reporting Entities (RREs). A copy of the CMS slides can be found here.

Why Section 111 Reporting Now Drives WCMSA Outcomes

CMS is increasingly using Section 111 reporting as a primary enforcement tool for post-settlement compliance and coordination of benefits.

As a result, reporting errors now create direct financial and compliance exposure. They may:

Eliminate the opportunity for CMS WCMSA review
Trigger incorrect Medicare denials
Create duplicate or inaccurate records in CMS systems
Increase exposure for both payers and claimants

WCMSA preparation, settlement strategy, and Section 111 reporting must now operate as a coordinated process.

TPOC Reporting Before WCMSA Approval Ends Review

The most significant takeaway from the webinar is this:

Reporting TPOC with an MSA amount before CMS approval will effectively end the WCMSA review process. CMS explained that Section 111 reporting is treated as the payer’s definitive representation of settlement posture. Once TPOC is reported with an MSA amount, CMS assumes the parties have elected a non-submit MSA strategy and will not reopen the matter for review.

CMS clarified that:

If TPOC is reported with a WCMSA amount, the Workers’ Compensation Review Contractor (WCRC) will not accept a new submission
If a WCMSA is already under review, the WCRC will close the file without issuing a determination

CMS’s position is that reporting TPOC signals the claim has settled and the parties have chosen to proceed with a non-submit MSA.

Key Risk

Reporting TPOC prematurely permanently removes the ability to obtain CMS approval, even if approval was originally planned.

CMS WCMSA Reporting Requirements You Cannot Ignore

Professional Administrator EIN Reporting

While the professional administrator’s EIN is technically optional, CMS made clear that even if there is an MSA professional administrator, failing to report it will result in the MSA being treated as self-administered.

Why it matters:

When misclassified as self-administered, CMS systems generate beneficiary correspondence that may conflict with the actual trust or professional administration arrangement, increasing beneficiary confusion and compliance disputes

Case Control Number (CCN) Requirements

For CMS-approved WCMSAs, the Case Control Number (CCN) must be reported, even though optional.

Why it matters:

Because CCNs are only assigned to CMS-approved WCMSAs, their absence in reporting is a key indicator to CMS systems that an MSA was not reviewed

Funding Method Must Match CMS Approval

CMS emphasized that the reported funding method must align exactly with the approval:

Lump sum approvals must be reported as lump sum
Structured approvals must be reported as structured

Any change to funding requires CMS approval before reporting.

CMS Introducing Tolerance for Minor Value Differences

CMS acknowledged that small discrepancies can occur between approved MSA amounts and reported values.

To address this, CMS has:

Eliminated sensitivity to cents
Introduced a tolerance threshold for minor variances

This reduces technical errors, but material discrepancies will still create issues.

WCMSA Reporting for Multiple Dates of Injury

CMS maintains its position on multi-date-of-injury settlements:

Report one TPOC and one WCMSA tied to the earliest date of injury
Since the WCMSA covers all settling dates of injury, include all diagnosis codes associated with all settled injuries under that earliest date

Additional dates of injury should still be reported, but with:

$0 WCMSA amounts

For example, if a settlement resolves three dates of injury, one claim should report the earliest DOI with the full WCMSA amount and all applicable diagnoses, while the remaining two claims are reported with zero-dollar WCMSAs

Common Section 111 Reporting Mistakes That Create Risk

CMS reinforced several expectations that, in practice, are common failure points:

Report only after the settlement is finalized*

Reporting a “pending” settlement date remains unacceptable

Ensure data accuracy across all systems

Misalignment between MSA vendors, claims teams, and reporting units is a frequent issue

Populate all applicable fields

“Optional” fields often drive how CMS classifies and processes the MSA. As such, some “optional” fields should be considered required.

*Finalized means all settlement terms are fully executed, court approval if needed, medicals released, and no further contingencies remain.

The consistent theme: incomplete or inconsistent data leads to downstream problems for both payers and beneficiaries.

How to Adjust Your WCMSA and Section 111 Process Now

Organizations should take immediate steps to align their processes with this guidance:

Do not report TPOC until WCMSA approval is obtained (if approval is being sought) and settlement is made final
Always include the CCN for CMS-approved MSAs
Treat the professional administrator EIN as required when applicable
Validate funding method and amounts before submission to ensure they match CMS approval
Implement controls for settlements with multiple dates-of-injury to ensure proper consolidation of diagnoses and reporting structure

Final Takeaway: Section 111 Is Now a Compliance Gatekeeper

CMS is increasing its reliance on Section 111 reporting to drive compliance and post-settlement enforcement.

Organizations that treat WCMSA approval, settlement negotiations, and reporting as separate workflows are at increasing risk of irreversible errors, particularly when TPOC is reported too early.

Getting this right now requires tighter coordination, stronger internal controls, and a more deliberate approach to settlement and reporting timing.

Tower MSA Partners helps organizations align WCMSA strategy with Section 111 reporting to reduce risk and improve outcomes. Contact our team to review your process. Please reach out to Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com with any questions.

Frequently Asked Questions

When should TPOC be reported for a WCMSA?

TPOC should be reported only after the settlement is finalized and medicals released (Indemnity-only settlements are not reported). If a WCMSA is being submitted for CMS approval, TPOC should not be reported until after that approval is received. Reporting too early can prevent CMS from reviewing the WCMSA.

What happens if TPOC is reported before CMS approval?

If TPOC is reported with a WCMSA amount before CMS approval, the review process will be terminated. CMS will not issue a determination, and the opportunity for approval is lost.

Is the professional administrator EIN required for WCMSA reporting?

While the EIN is technically optional, CMS may treat the MSA as self-administered if it is not reported. This can lead to incorrect assumptions about how the MSA will be managed and may impact communication with the beneficiary.

What is a CCN in WCMSA reporting

CMS assigns the Case Control Number to track approved WCMSAs. It must be included in Section 111 reporting to ensure accurate recordkeeping and proper coordination of benefits.

How does CMS manage multiple dates of injury in WCMSA reporting?

CMS requires one WCMSA to be reported and tied to the earliest date of injury. All related diagnoses for the settled injuries should be included under that claim. Additional dates of injury should still be reported, but with zero WCMSA amounts.

$210K Saved: Why Clinical Oversight Is the Hidden MSA Advantage

April 9, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 7 Clinical Oversight Savings

In Tower MSA Partners’ last post, $231K in Savings from Free Physicians Follow-Up, we demonstrated how ongoing medical review produced $231K in savings through free physician follow-up. This month, we highlight the broader impact of clinical oversight itself. A payer asked Tower MSA Partners to review a complex claim involving long-term pain management, active comorbidities, and multiple prescribing providers. Through clinical oversight, Tower identified inaccuracies and outdated treatments that reduced the projected allocation by $210,143 (approximately $210K). This case reinforces why clinical insight is a powerful advantage in Medicare Set-Aside (MSA) management.

Identifying the Problem

The claim had a long history of treatment, frequent medication changes, and overlapping specialties that created inconsistencies in documentation. The initial MSA prepared by another vendor included medications that were no longer prescribed, therapy frequencies that were inconsistent with current care, and several treatments that lacked documentation supporting ongoing medical necessity. Without clinical oversight, these issues would have resulted in inflated costs and potential CMS challenges. The payer needed an accurate allocation that reflected the claimant’s present health status and documented treatment plan.

The Clinical Oversight Solution

Tower MSA Partners conducted a comprehensive clinical review of all medical records, pharmacy histories, diagnostic reports, and provider notes. The clinical team identified medications that had been discontinued, adjusted prescription regimens based on updated records, and corrected treatment frequencies. The review also uncovered redundant therapies that no longer aligned with best practice guidelines. Each correction was supported with clinical rationale and evidence-based justification. After applying these corrections, the revised MSA decreased by $210K while meeting all CMS expectations for accuracy and documentation.

Collaboration and Communication

Tower’s team worked closely with the claims professional to explain each update and its clinical foundation. Clear communication ensured that all parties understood the reasoning behind each correction. Defense counsel and treating providers were involved as needed to validate treatment patterns and confirm medication changes. This collaborative approach helped create a strong, defensible MSA that moved through CMS review without additional development requests. Precise documentation and clinical clarity built confidence across the entire review chain.

Why Oversight Makes the Difference

Clinical oversight strengthens MSA accuracy by applying an evidence-based medical lens instead of a purely administrative review, ensuring allocations are clinically appropriate and defensible under CMS review. Over time, complex claims develop treatment patterns that do not always reflect current clinical standards or actual patient needs. By applying clinical judgment, Tower identifies outdated or unnecessary items that inflate lifetime costs and weaken compliance. This case shows how oversight protects payers from significant overfunding while ensuring the MSA remains a true reflection of medically necessary care.

Lessons Learned

· Clinical oversight reveals inconsistencies that administrative reviews often miss.

· Updated medical documentation ensures accurate and defensible MSA projections.

· Collaboration with providers strengthens clarity around treatment plans.

· Savings come from clinically guided corrections and accurate projections.

· The $210K reduction resulted from correcting outdated services and aligning projections with best practice.

Results That Reflect Expertise

The payer saved $210K and gained a fully compliant, defensible MSA supported by updated medical documentation and evidence-based clinical review. Tower MSA Partners demonstrated how clinical insight delivers meaningful savings while strengthening the accuracy and defensibility of every allocation. Clinical oversight is an essential advantage in managing complex claims and achieving both cost containment and compliance excellence.

FAQs

What is clinical oversight in MSA review?
Clinical oversight is a medically guided evaluation of an MSA that ensures treatments and medications reflect current clinical standards and documented medical necessity.

How does clinical oversight reduce MSA costs?
It identifies outdated treatments, incorrect therapy projections, and discontinued medications that inflate lifetime medical costs.

When is clinical oversight most valuable?
It is essential for complex claims involving long-term treatment, multiple providers, or frequent medication changes.

Does CMS recognize clinically supported changes?
Yes. CMS accepts proposed MSA amounts when they are supported with accurate clinical documentation and clear reasoning.

CMS will host a webinar on WCMSA Reporting on April 15

March 14, 2026

CMS will host a webinar on WCMSA reporting on March 25, 2026 at 1:00 p.m. ET to review reporting requirements, common issues, and best practices.

The Centers for Medicare and Medicaid Services will host a webinar on Workers’ Compensation Medicare Set-Aside (WCMSA) Reporting on Wednesday, April 15, 2026, at 1:00 p.m. ET.

Per CMS:

CMS will be hosting a WCMSA Reporting Webinar. The intent of the webinar is to review

the WCMSA reporting process that was implemented in April 2025, discuss some of the

issues encountered from CMS’ perspective, and review WCMSA reporting best practices.

As parties impacted by the WCMSA reporting, we also welcome anyone else involved in

the submission and administration of WCMSAs, including attorneys and Medicare

beneficiaries, to join. Please bear in mind that this Webinar is intended to broadly address

the WCMSA reporting process and questions regarding specific cases are not appropriate

for this setting.

There is no pre-registration for the webinar. Full details, including instructions on how to submit questions before the webinar, are available here and in the “What’s New” section of the CMS website.

Premier Webinar: MSP Compliance in 2026 – Regulatory Updates, Section 111 Audits & Settlement Risk

March 9, 2026

Tower MSA Partners webinar banner for “MSP Compliance in 2026, Section 111 Audits and Settlement Risk” on March 11, 2026 at 2 PM ET.

In 2025, the Medicare Secondary Payer landscape changed in meaningful ways. Section 111 WCMSA reporting became operational, and CMS discontinued formal review of $0 MSAs—fundamentally altering how payers approach settlement strategy and compliance risk.

Now in 2026, CMS is preparing to initiate its first round of Section 111 reporting audits.

What does all this mean for carriers, self-insureds, and defense counsel?

On Wednesday, March 11 at 2:00 p.m. ET, join Tower’s Chief Compliance Officer, Dan Anders, for a focused, practical discussion on how these regulatory developments are impacting workers’ compensation claims handling—and what organizations should be doing now.

You will learn:

The current status of Section 111 WCMSA reporting and how it is affecting settlement negotiations
What to expect from upcoming CMS Section 111 audits, including likely audit focus areas and compliance vulnerabilities
How to evaluate and document $0 MSAs in the absence of formal CMS review
Emerging MSA trends based on recent CMS guidance and Tower benchmarking data
Practical steps to mitigate civil money penalty exposure and strengthen internal controls

A Q&A session will follow the presentation. Questions may be submitted in advance during registration.

Please reserve your spot today.

Registration link: https://attendee.gotowebinar.com/register/3480677134558573406

$231K in Savings from Free Physician Follow-Up

March 4, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 6 $231K in Savings from Free Physicians Follow-Up.

In Tower MSA Partners’ previous post, Trimming the Fat, $175K in Savings Through MSA Optimization, we explained how MSA optimization removed $175,000 in unnecessary projected costs. In this case, a payer asked Tower to validate the treatment plan for a complex claim through physician follow-up. By engaging the treating provider, confirming current medical needs, and obtaining a physician attestation, Tower reduced the projected Medicare Set Aside (MSA) lifetime cost by $231,487 and secured CMS acceptance without development.

Identifying the Problem

The claimant’s original MSA had been created more than two years earlier. Since that time:

Multiple prescriptions were listed without up-to-date clinical context
Treatment frequency and diagnoses were not validated
The projected costs reflected outdated assumptions

Without direct clinical confirmation, the allocation risked inflating projected future costs and faced potential CMS scrutiny. The payer needed a defensible allocation grounded in current medical reality.

The Physician Follow-Up Solution

Tower’s clinical team initiated physician follow-up, adhering to jurisdictional rules for secure outreach. The process included:

Reviewing the full set of updated medical records
Confirming active medications, dosages, and indications
Discussing current therapy frequency with the treating physician
Validating the absence or tapering of unnecessary prescriptions

The physician confirmed that the only active prescription was Oxycodone/APAP 5/325 mg and that certain therapies were no longer needed. Armed with this clinical confirmation and a signed attestation, Tower updated the allocation.

The result was a $231,487 reduction in projected MSA costs — fully documented, fully supported, and defensible.

Collaboration and Communication

Tower MSA Partners didn’t just update numbers in a spreadsheet. Every correction was explained clearly to the claims professional and documented. The physician’s signed attestation — verifying current care and confirming that outdated items were no longer clinically necessary — was included in the CMS submission.

Because the revised MSA included accurate current clinical information and a valid attestation, CMS approved the allocation quickly and without development requests.

Why Physician Follow-Up Makes the Difference

Treatment plans evolve, medications change, and assumptions in an early allocation can become outdated. Without direct validation from the treating physician:

Medications may be mischaracterized
Frequencies may be overstated
Lifetime projections may overestimate future care

Physician follow-up ensures the MSA reflects actual current need, which:

Controls costs
Enhances compliance
Strengthens defensibility in CMS review

This case shows that physician engagement isn’t a luxury — it’s a strategic lever for both accuracy and savings.

Lessons Learned

Physician engagement validates clinical need and clarifies current care.
Signed attestations give CMS confidence in the accuracy of the allocation.
Outdated medications and therapies can be confidently removed when confirmed to be clinically unnecessary.
Defensible projections protect payers from excess costs and speed CMS review.

Results That Reflect Expertise

With targeted physician follow-up and attestation:

The payer realized $231,487 in reduced lifetime MSA costs
The updated allocation aligned with clinical reality
CMS approved the allocation without development requests

Tower MSA Partners delivered transparent documentation, accurate projections, and a cost-conscious, defensible settlement outcome.

FAQs

What is physician follow-up?

Physician follow-up is direct communication by Tower with the treating provider to confirm current medical treatment, active medications, and therapy needs. It ensures MSAs reflect accurate, individualized clinical information.

How does physician follow-up create savings?

By validating care with the treating physician, unnecessary treatments and medications can be removed or corrected in the lifetime projection, reducing projected future costs.

Is physician follow-up accepted by CMS?

Yes. When physician follow-up includes clear clinical documentation and, if required, a signed statement, CMS will accept updated MSAs and often approves them without development requests.

When should physician follow-up be used?

Physician follow-up can be used anytime there is open-ended medical care, outdated treatment recommendations or inconsistent or contradictory medication history.

Trimming the Fat, $175K in Savings Through MSA Optimization

February 3, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 5 Trimming the Fat with MSA Optimization

In Tower MSA Partners’ previous post, we showed how a MSA second opinion review helped a payer avoid ninety-eight thousand dollars in unnecessary allocation. This month, we look at a case study on how targeted MSA optimization can uncover even larger savings. Tower MSA Partners reviewed a complex claim with significant pharmacy exposure and identified an opportunity to reduce projected costs by $175,000. This case shows how structured review protocols and clinical oversight create precise and defensible MSAs.

Identifying the Problem

The claimant had a long-term injury that included frequent therapy, diagnostics, and multiple ongoing prescriptions. The initial MSA prepared by another vendor included duplicate entries, outdated treatments, and medications that had been replaced with safer and more cost-effective alternatives. Therapy frequency was also projected far beyond what the medical records supported. These inaccuracies created an inflated allocation that did not reflect current treatment patterns.

The MSA Optimization Solution

Tower MSA Partners completed a full optimization review and reconciled every projection with the latest medical records. Our clinical team verified treatment frequency, evaluated pharmacy histories, and confirmed whether each medication remained clinically appropriate. Outdated therapy, legacy prescriptions, and inaccurate frequency projections were removed or corrected. Each modification included detailed clinical reasoning and clear documentation. After optimization, the MSA decreased by $175,000 and remained fully aligned with CMS expectations. The updated allocation represented the claimant’s true medical needs without unnecessary inflation.

Collaboration and Communication

As with all Tower reviews, collaboration played a significant role. The clinical team walked the claims professional through each correction and clarified why the original allocation overstated ongoing care. Defense counsel and treating providers were updated as needed to confirm accuracy and alignment with the medical record. The optimized MSA was submitted to CMS with strong supporting documentation and was approved without development requests.

Why Oversight Makes the Difference

MSA optimization is not simply cost-cutting. It is a structured validation process that ensures every projected service is clinically necessary and supported by current documentation. Removing outdated items protects payers and claimants from unnecessary costs and strengthens the defensibility of every file. This case demonstrates how careful review drives savings.

Lessons Learned

MSA optimization identifies inaccurate or outdated projections that inflate lifetime medical costs.
Clinical oversight ensures medications and treatments reflect current best practice.
Documentation clarity leads to predictable CMS approval.
Savings come from precision. The $175,000 reduction resulted from accurate alignment with the medical record.

Results That Reflect Expertise

The optimized MSA saved the payer settlement monies and produced a compliant, defensible allocation supported by current documentation. Tower MSA Partners continues to demonstrate how clinical accuracy, alignment with CMS, and detail-oriented review generate meaningful and measurable results. Optimization is an essential tool in responsible claims management.

FAQs

What is MSA optimization

MSA optimization is a detailed clinical review that removes outdated treatments, corrects inaccurate projections, and ensures the allocation reflects current medical necessity.

How does optimization reduce allocation amounts

Optimization aligns treatment and pharmacy projections with the actual medical record, which eliminates unnecessary costs and outdated services.

When should an MSA be optimized

It is recommended for claims with long-term treatment, complex pharmacy needs, or significant changes in care since the initial projection.

Does CMS accept optimized MSAs

Yes. CMS accepts optimized MSAs when the updated allocation includes clear clinical documentation and accurate reasoning for the projected future medical.

Key Takeaways from CMS Webinar on Civil Money Penalties

January 21, 2026

On January 15, 2026, CMS held a webinar on Civil Money Penalties (CMPs) for Non-Group Health Plan (NGHP) Section 111 Reporting. This was CMS’s final update before the first audits and penalty notices in the first quarter of 2026. Given that penalties can be substantial and impact an organization’s compliance record, understanding these requirements and deadlines is essential for all Responsible Reporting Entities (RREs).

CMS provides a full explanation of its CMP policy on its website here.

Quick Reference: Critical Dates

February 2026: First CMS audits begin
March 2026: First penalty notices expected
July 2026: Workers’ compensation penalty assessments begin

Audits

CMS will conduct its first audits in February 2026. The audit will randomly select 250 records from all accepted Section 111 records and non-Section 111 records obtained through CMS’s coordination of benefits and data collection methods. The 250 records will proportionally represent both NGHP and Group Health Plan (GHP) records from the prior quarter.

For the February 2026 audit, CMS will evaluate records accepted between October 11, 2025, and December 31, 2025. CMS will look forOngoing Responsibility for Meedicals (ORM) assumptions or Total Payment Obligation to the Claimant (TPOC)(TPOC) reported more than 365 days after the reportable event. This applies to ORM assumptions and TPOC dates of October 11, 2024, or later.

What Triggers Penalties

Penalties are assessed when RREs fail to report required information within mandated timeframes. Specifically, CMS looks for:

ORM assumptions reported more than 365 days after the reportable event
TPOCs reported more than 365 days after the reportable event

Special Consideration for Workers’ Compensation

As a result of the implementation of WCMSA reporting in April 2025, CMS announced that it will not assess penalties for late-reported workers’ compensation TPOCs until July 2026, with a lookback period to July 2025 instead of October 11, 2024. This grace period allows RREs to adjust to the new WCMSA reporting requirements.

Safe Harbor Protection

CMS provides a safe harbor when an RRE cannot report a TPOC because the claimant failed to provide information necessary to identify them as a Medicare beneficiary (such as their Social Security number).

Requirements to qualify for safe harbor:

Make two attempts to obtain the information from both the beneficiary and their attorney by mail or email
Make one additional attempt to either the beneficiary or their attorney by phone, mail, or email
Document all attempts with dates, methods, and responses
If either the claimant or their attorney provides a written refusal to cooperate, no further attempts are needed

Important notes:

Federal law does not prohibit the RRE from contacting the claimant directly, even when the claimant is represented by an attorney
Contact must be made with both the attorney and the claimant until one of them either provides the information or provides a written refusal

All documentation of these attempts must be retained and provided to CMS if a penalty arises.

Acceptable documentation includes copies of emails, certified mail receipts, phone logs with dates and summaries of conversations, and written refusals.

Penalty Notice Process

Informal Notice

CMS expects the first penalty notices to be sent in March 2026. These informal notices will be mailed to the RRE’s Authorized Representative, with a copy to the Account Manager. Importantly, the reporting agent (such as Tower or other third-party administrators) will not be copied on the notice.

Action required:

Given the importance of receiving these notices, RREs should immediately verify that their Profile Report contains up-to-date contact information for both the Authorized Representative and Account Manager.

Upon receipt of an informal notice, the RRE has 30 days to provide a response, including a reasonable explanation as to why either the TPOC report or the ORM assumption report was untimely.

Possible defenses include:

The claimant refused to provide their Social Security number (safe harbor applies)
Delayed acceptance of a claim due to litigation or investigation
Administrative errors with documented corrective measures
Technical issues with CMS submission systems

If CMS accepts the explanation, there will be no further action.

WC Reporting Penalties

Formal Notice

If CMS does not accept the explanation or there is no response to their informal notice, a formal notice, called a Notice of Proposed Determination to Impose a Civil Money Penalty, will be mailed to the Authorized Representative and copied to the Account Manager for the RRE.

Appeals Process

The appeals process provides multiple levels of review:

Level 1 – Administrative Law Judge (ALJ): The RRE has 60 days from receipt of the Proposed Determination to appeal to an ALJ.

Level 2 – Departmental Appeals Board: If the ALJ’s decision is unfavorable, the RRE has 30 days to file an appeal with the Departmental Appeals Board Appellate Division.

Level 3 – Federal Court: If the Departmental Appeals Board appeal results in an unfavorable decision, the RRE has 60 days to petition for judicial review in federal court.

Payment

Once the appeals process has concluded, or if no appeal is filed, a Notice of Final Determination will be sent to the RRE. The RRE has 60 days from receipt to make payment electronically through pay.gov.

Best Practices and Final Thoughts

The timeliness and accuracy of Section 111 reporting will mitigate and, ideally, eliminate any possibility of a penalty. To protect your organization:

Proactive measures:

Implement robust processes to capture Medicare beneficiary information at first contact
Establish clear procedures for the three-attempt safe harbor requirement with documentation templates
Maintain detailed records of all attempts to obtain beneficiary information
Review and update your CMS Profile Report contact information immediately
Develop internal timelines that build in buffer time before the 365-day reporting deadline

If you receive a penalty notice:

Respond immediately within the 30-day window
Coordinate with your Section 111 reporting agent, if applicable, to identify all possible defenses
Gather all documentation supporting your explanation

Please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com with any questions.

A $98K Mistake Avoided, The Value of Second Opinion MSA Reviews

January 12, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 4 A $98K Mistake Avoided with a Second Opinion MSA Review

In Tower MSA Partners’ previous post, we explained how Physician Peer Review generated more than one million dollars in savings while strengthening CMS compliance. This month, we shift focus to the importance of accuracy. Tower MSA Partners was asked to review a Medicare Set Aside allocation prepared by another company, and the findings revealed a significant error that would have cost the payer ninety eight thousand dollars. This case illustrates why a second opinion is a valuable safeguard in every MSA strategy.

Identifying the Problem

The claim involved ongoing treatment, therapy, and pharmacy exposure. The original MSA prepared by another vendor appeared complete, and the projected costs seemed typical for this type of injury. Once Tower MSA Partners reviewed the file, the clinical team found inconsistencies that required deeper investigation. Several treatment projections did not align with the documented medical record. The file also listed duplicate items and outdated medications that had already been removed from the claimant’s regimen. The largest issue involved a discontinued high-cost prescription that remained in the allocation. This error inflated the MSA by nearly one hundred thousand dollars and created unnecessary CMS risk. If submitted as written, the payer would have funded care that no longer existed and faced questions about clinical justification.

The Second Opinion Solution

Tower MSA Partners completed a complete second opinion MSA review. Analysts verified each treatment recommendation and cross-referenced records with the most current documentation. Pharmacy history was compared to recent physician notes to ensure accuracy. The discontinued medication was the key discrepancy. The treating physician had replaced it with a lower cost, safer alternative, and the original reviewer failed to revise the allocation. Tower updated the MSA to reflect the correct medication plan and documented the clinical reasoning in clear, concise terms. With the correction in place, the projected cost of the MSA decreased by ninety-eight thousand dollars while maintaining complete alignment with CMS guidance.

Collaboration and Communication

Tower MSA Partners emphasizes transparency in every step of the review. The clinical team explained each correction and helped the claims professional understand why the original allocation was inaccurate. This clarity supported confident decision making and prepared the file for CMS submission. Tower also communicated updates with the defense attorney and treating provider, so all parties understood the medical basis for the revisions. When submitted to CMS, the revised MSA was approved without development requests. Accurate documentation and clinical alignment created a predictable approval process.

Why Oversight Makes the Difference

Accuracy is essential in Medicare Set Aside management. Even a small oversight can inflate lifetime medical projections and expose the payer to avoidable costs. A second opinion MSA review provides an essential layer of validation that confirms medical necessity, eliminates outdated information, and protects the overall integrity of the claim. This case demonstrates that clinical oversight and cost savings work together. Correcting the allocation not only protected the payer from unnecessary spending but also ensured that the file met CMS expectations with confidence.

Lessons Learned

A second opinion review prevents costly mistakes and confirms accuracy before submission.
Outdated information leads to inflated costs, especially in pharmacy heavy claims.
Strong clinical documentation makes CMS approval predictable and efficient.
Precision drives savings. The ninety-eight-thousand-dollar reduction resulted from careful review and experienced analysis.

Results That Reflect Expertise

By requesting a second opinion, the payer avoided a ninety-eight thousand-dollar over allocation and gained a compliant, defensible Medicare Set Aside. The corrected review reflected actual medical necessity and prevented unnecessary long-term funding. This case highlights Tower MSA Partners’ continued commitment to accuracy, clinical alignment, and cost containment. A second opinion review is more than a quality check. It is an essential safeguard for payers, claimants, and settlements.

FAQs

What is a second opinion MSA review?

A second opinion review evaluates an MSA prepared by another company to confirm accuracy, clinical validity, and compliance with CMS guidelines.

How do second opinions create savings?

They uncover outdated treatments, discontinued prescriptions, and projection errors that inflate total costs.

When should a second opinion be considered?

Any claim with complex medical history, high pharmacy exposure, or uncertainty about the accuracy of an existing MSA benefits from a second opinion.