artefact_admin, Author at Tower MSA

Updated CMS Policy Changes Medicare Set-Aside Seed Calculation

April 29, 2021

book marked by sticky notes illustrating changes Section 111 reporting on ORM

An updated CMS policy change to the Workers’ Compensation MSA Reference Guide changes the Medicare Set-Aside seed calculation

On April 19, 2021, the Centers for Medicare and Medicaid Services (CMS) released an updated Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide, Version 3.3, which made a slight but notable addition to how the Medicare Set-Aside seed calculation seed amount is determined. Specifically, CMS now requires the MSA seed amount to include the cost of the first surgery/procedure for each body part. Previously, CMS accepted only one surgery in the seed even when there were additional surgeries for other body parts in the MSA allocation.

When settling parties choose to fund the MSA with an annuity, there is an initial deposit called the seed amount. The seed amount, under the prior rule, included the first two years of annual payments and, when applicable, the cost of the first surgery/procedure, the first replacement DME if the cost exceeds $500 and sometimes injections.

For example, an overall Medicare Set-Aside amount of $100,000 might breakdown to a $25,000 seed amount (with one surgery) with the remaining $75,000 placed in an annuity.

Under the new rule, requiring the Medicare Set-Aside seed calculation amount to include the first surgery for each body part does not change the overall MSA amount, but it puts more funds in the seed amount and less in the annuity. With the annuity less, the cost to the employer or carrier to fund the MSA will be more. In other words, taking the above example, where previously the seed amount was $25,000 (to include one surgery), the seed may now be $45,000 (to include two surgeries) with the annuity only funding $55,000.

CMS also made some other minor changes in this updated guide:

Updated the link to the CDC Life Expectancy table used by CMS (Section 10.3)
Added language confirming medication refills should be included when pricing intrathecal pumps (Section 9.4.5)
Noted that a Consent to Release “must be signed (by hand or electronically) with the full name of either the claimant, matching the claimant’s legal name, or by the claimant’s authorized representative, if documentation establishing the relationship is also provided. It must be a full signature, not initials.” (Section 10.2)
Clarified section regarding access to cases via the WCMSA Portal for Professional Administrators that were not the original submitters (Sections 16.2 and 19.4)
Updated the Major Medical Centers table for a Missouri entry (Appendix 7)
Added disclaimer to Appendix 4 stating that CMS does not endorse any of the listed products it uses for reference in calculating the MSA.
Noted that Conduent Strataware® was added to Appendix 4 as a tool for repricing medical bills to state mandated fee schedules, as well as usual, customary and recommend rates.

If you have any questions about these updates, please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com or (888) 331-4941.

Related Prior Posts:

CMS Adds New Pricing Resource to WCMSA Reference Guide

CMS Expands MSA Amended Reviews & Modifies Consents to Release in Updated Reference Guide

Tower MSA Partners Completes SOC 2 Type II Audit

April 28, 2021

In our unwavering commitment to data privacy and security, Tower MSA Partners has completed its SOC 2 Type II audit. The SOC 2 Type II audit reports on a service organization’s non-financial reporting controls and processes as they relate to the Trust Services Criteria developed by the American Institute of Certified Public Accountants (AICPA). It tests the organization’s controls related to security, availability, processing integrity, confidentiality, and privacy over an extended period of time.

From the beginning, Tower has been committed to technology driven processes to bring efficiency and measured results to our clients. The SOC 2 Type II attestation demonstrates how our corporate governance effectively assesses and manages risks and ensures the integrity of the systems and processes delivered by Tower and its business partners to execute the same high level of protection throughout the supply chain. I’m extremely proud of this leadership team and its accomplishments.

Conducted by KirkpatrickPrice, the audit verified the fairness of the presentation of management’s description of the service organization’s system and the suitability of the design and operating effectiveness of the controls to achieve the related control objectives included in the description throughout a specified period.

“Tower delivers trust-based services to their clients, and by communicating the results of this audit, their clients can be assured of their reliance on its controls,” said KirkpatrickPrice President Joseph Kirkpatrick.

Related Prior Posts:

Tower MSA Partners Receives SOC 2 Type I Attestation

Building a Better Tower

CMS Updates Section 111 Model Language Form

April 26, 2021

Man signing a document to illustrate CMS updates to Section 111 Model Language Form

Recently, the Section 111 Model Language form was updated by the Centers for Medicare and Medicaid Services (CMS), The form is used by Responsible Reporting Entities (RREs) to collect the Medicare Beneficiary Identifier (MBI) and/or a Social Security Number (SSN) from claimants. The SSN or MBI, along with the claimant’s First and Last Name, Gender, and Date of Birth, are needed by the RRE to query CMS to determine whether the claimant is a Medicare beneficiary for Section 111 Mandatory Insurer Reporting purposes.

The most notable change to the form is that the Section I language was revised from “Are you presently, or have you ever been, enrolled in Medicare Part A or Part B?” to “Are you presently, or have you ever been, enrolled in Medicare?” We assume this language was modified because the claimant’s enrollment in Parts A, B, or C (which isn’t even mentioned) is irrelevant for purposes of Section 111 reporting. The simpler language, just asking for Medicare enrollment status, should avoid confusion that may have arisen from the prior language.

Practical Implications of the Section 111 Model Language form

As we wait for CMS to issue final rules around mandatory insurer reporting penalties, it is important for RREs and those administering claims for RREs to collect this identifying information or document their efforts to collect it by using this model language. As we discussed in CMS Issues Proposed Rule for Mandatory Insurer Reporting Penalties, RREs will have a safe harbor from reporting penalties if they document good faith efforts to attempt to obtain an MBI or SSN from the claimant, and this model form will help document those efforts.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with comments or questions.

Related Posts

Section 111 Reporting

Dan Anders in WorkCompWire: Avoiding Section 111 Reporting Penalties

CMS Section 111 Mandatory Insurer Reporting Webinar Recap

April 7, 2021

man on keyboard for Section 111 Mandatory Insurer Reporting

Leaders from the Centers for Medicaid and Medicare Services (CMS) Division of MSP Program Operations, Commercial Repayment Center (CRC), and Benefits Coordination and Recovery Center (BCRC) held an April 1 webinar on the intersection of the BCRC and CRC in Section 111 Mandatory Insurer Reporting and the resolution of Medicare conditional payments.

While mostly a Q&A format, the webinar unveiled a new CMS/BCRC policy for reporting partial settlement of medical when Ongoing Responsibility for Medical (ORM) ends for certain diagnoses and continues for others. Set to rollout in June, the new reporting policy provides for three scenarios:

Partial settlement of medical prior to initial reporting

Scenario: Claimant is identified as a Medicare beneficiary which triggers the requirement to report ORM and/or Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process. Both ORM and TPOC are for the same insurance type, policy, and claim number. The only difference is the accepted and denied diagnoses on the claim. The parties agree to a partial settlement for the denied diagnoses and leave the accepted diagnoses open on the claim.

Problem: How to report a partial settlement of the denied diagnoses and still report ORM for the accepted diagnoses.

CMS Solution: CMS’s solution is to submit two add records. Specifically, one record will be added for ORM that will describe all of the diagnoses that have been accepted for ORM. ORM will be ‘Y’ with no TPOC date or amounts. A second record will be added for TPOC which will describe all of the denied diagnoses that are being settled. ORM will be ‘N’ with a TPOC date and amount.

Partial settlement of medical post initial reporting

Scenario: A claim with multiple diagnoses was reported for ORM through the Section 111 Mandatory Insurer Reporting process. The parties agree to a settlement for certain diagnoses while keeping ORM open for other diagnoses.

Problem: How to report a partial settlement for certain diagnoses while keeping ORM open for the non-settled diagnoses.

CMS Solution: CMS’s solution is to submit one update record and one add record. The update record will remove the diagnoses that are subject to the partial settlement and keep the diagnoses codes where ORM continues. Then, an add record with the TPOC date, amount and diagnoses codes that are subject to the partial settlement will be submitted. ORM will remain “N” in the add record.

Partial ORM closure with no settlement

Scenario: Acceptance of ORM is initially reported though the Section 111 Mandatory Insurer Reporting process with multiple diagnoses. Subsequent to this initial report, there is a basis to terminate one or more of the initially accepted diagnoses, but not all of the diagnoses. This is not a situation where a partial settlement has occurred, rather there is a basis to terminate one or more diagnoses absent a settlement. For example, a claimant’s cardiac condition was exacerbated as a result of a fall and the medical providers confirm resolution of the exacerbation. While the carrier continues to accept the orthopedic condition, the ORM can end for the cardiac diagnosis.

Problem: How to end ORM for one or more diagnoses while keeping it open for other diagnoses.

CMS Solution: CMS’s solution is to send an update record that removes the diagnosis or diagnoses where ORM has ended. In this situation a TPOC date is not submitted, rather this is only submitted when ORM is completely terminated for all diagnoses.

The purpose behind these new policies is to improve coordination of benefits such that a Medicare beneficiary’s medical care is not denied when unrelated to a claim and prevent the recovery contractors from attempting to seek reimbursement for Medicare payments unrelated to a claim.

While we thank CMS and the BCRC for identifying solutions to the above reporting problems, we believe RREs may face some technical challenges in the ability to, for example, report two add records on the same claim. We await issuance of the formal policy from CMS and will review how this policy change can best be incorporated into the Section 111 reporting process.

In addition to announcing the new reporting policy, CMS and the contractors provided the following advice:

Respond to correct contractor – Carefully review the correspondence and make sure to respond to the contractor that sent the letter, whether it’s to obtain further information, dispute/appeal charges, or to make payment.

As a reminder, CMS noted, the BCRC is generally recovering conditional payments when the identified debtor is the Medicare beneficiary while the CRC is recovering conditional payments when the insurer/WC carrier is the identified debtor.

CMS provided the following guidance regarding key timeframes:

Interest accrues from the date of the demand letter and is assessed on debt if not resolved within 60 days.
- When CMS issues a demand letter directly to the applicable plan, the applicable plan has formal administrative appeal rights.
- The applicable plan has 120 days from the date the applicable plan receives the demand letter to file a redetermination (first level of appeal). Interest will still accrue during this time.
- If the appeal is not filed within 120 days, and “good cause” for untimely filing is not provided, the appeal will be dismissed.
- Failure to resolve the debt will result in referral to treasury at 180 days.

Note: When you are appealing to the ALJ please be sure to cc the CRC so that they can appropriately place a hold on a case so that it is not referred to treasury while the appeal is in process.

During the Q&A portion of the webinar CMS and its contractors addressed varied questions; some are summarized below:

What can be done if we cannot obtain a Social Security number from the claimant? CMS advised them to document their efforts at obtaining the SSN. It was noted CMS has model language found on the CMS website which can be used to document claimant’s refusal to provide SSN.
In response to a question concerning the many charges found on conditional payment notices and demands that are unrelated to the injury, CMS/CRC acknowledged that it is not a perfect process. The CRC explained that when conditional payment information is requested what is sent to the requestor may have only been produced through an automated search of charges related to the injury. CRC did advise that when it comes to actual issuance of a demand that there is a human validating process.
In response to a question concerning why in response to a dispute of a Conditional Payment Notice, one might receive another CPN with new charges, the CRC explained that this is the result of the system constantly reviewing for additional charges deemed related to the injury.
There were several questions regarding problems with the CRC recognizing out-of-pocket reimbursements to claimants in a no-fault/med-pay claim as counting towards the exhaustion of the no-fault maximum amount. CRC’s response was to advise entities to provide plan documents and proof of payment to the claimant along with a reason for the payment. Its leader said, “We are aware that no-fault payors have run into problems with CRC rejecting out-of-pocket expenses as included within the no-fault exhaustion amount.”

If you have any questions, please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.

Related prior posts:

CMS RELEASES TECHNICAL UPDATES TO SECTION 111 USER GUIDE

MSPN Elects Dan Anders as President

February 3, 2021

Dan Anders who was quoted in the Claims Journal

Tower’s Chief Compliance Officer, Dan Anders, has been elected president of the National Medicare Secondary Payer Network (MSPN). MSPN is the premier organization for individuals, companies and law firms who want to stay apprised of Medicare Secondary Payer compliance developments and collaborate on industry leading education and advocacy efforts. Check out the news release: Tower MSA Partners Dan Anders Elected President of the National Medicare Secondary Payer Network.

This is the second time in three years Tower has had one of our executives at the helm of this organization. Our CEO, Rita Wilson, served as president in 2018.

Dan takes office as the organization completes rebranding itself from its former name of the National Alliance of Medicare Set-Aside Professionals (NAMSAP) to the National MSP Network. Over the years, the Centers for Medicare and Medicaid Services (CMS) expanded its MSP enforcement mechanisms beyond Medicare Set-Asides. The organization kept pace, adding Medicare conditional payment recovery, mandatory insurer reporting to Medicare, and MSA professional administration and settlement structuring to its education and advocacy initiatives.

Dan looks forward to working with MSPN’s Executive Committee and Board, consisting of the most experienced and knowledgeable professionals in the MSP compliance community, to accomplish the organization’s 2021 goals.

Additionally, he will continue the organization’s positive working relationship with CMS’s Division of MSP Program Operations, which enables MSPN members to ask questions and raise concerns and provide solutions directly with those who develop and implement MSP policy while learning the agency’s reasoning and viewpoint firsthand.

If you would like to learn more about MSPN, please contact Dan Anders at daniel.anders@towermsa.com or (888) 331-4941, ext. 219.

Tower MSA Partners Wishes You a Warm & Restful Holiday Season

December 22, 2020

a sprig of holly and the words Happy Holidays

This year has brought deeper meaning to traditional holiday wishes. We are thinking about our health, families, and partners in different ways and re-thinking priorities. But as we adapt to new realities, our commitment to you–our partners–is unwavering. Thank you for your loyalty during this challenging year.

We sincerely hope you enjoy a happy and healthy holiday.

Your friends at Tower MSA Partners

November CMS News: Mandatory Reporting and Conditional Payment Updates

November 24, 2020

Hand writing What's New?" on a chalkboard for CMS news update

Here’s a recap of recently announced CMS news:

CMS News #1: Medicare Conditional Payment Appeals Guide

In follow-up to its September 2020 webinar on Medicare conditional payment appeals through the Commercial Repayment Center (CRC), CMS converted the slides into an appeals guide. The guide, which can be found here, provides a breakdown of the Medicare conditional payment appeals process and the bases for appeals.

CMS News #2: Updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Guide

Earlier in November, CMS released a Technical Alert and an updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting User Guide, Version 6.1, to announce “Section 111 Edits to no Longer Cause Record to Reject.”

In short, starting April 5, 2021, several error codes will be converted into what CMS calls “soft edits.” Soft edits are still considered errors by CMS but will not cause the entire record to be rejected. Examples of such data errors are in fields reporting middle initial of claimant’s name and alleged cause of injury. The Responsible Reporting Entity (RRE) is still responsible for correcting these errors in the next quarterly file submission.

Additionally, a new soft edit will be added and applied to NGHP Claim Input File Detail Record files when users submit a no-fault insurance claim where the policy limit is less than $1000.00. The input files will be accepted but a new CP13 error will be returned on the response files.

Finally, Claim Input File Detail Records submitted prior to the effective date of the injured party’s entitlement to Medicare will be rejected and returned with a Disposition Code ‘03’ instead of an SP31 error. As a result, if the purpose of the report was to indicate ongoing responsibility for medicals has been accepted (ORM=Y), then the claim will need to be re-submitted in the next quarterly reporting period (at which point the claimant is presumably entitled to Medicare).

CMS News #3: CMS to Host BCRC Recovery Process Webinar

On Wednesday, December 9, 2020 at 1:00 PM ET, CMS will be hosting a webinar focused on the Medicare Secondary Payer (MSP) recovery process when a Medicare beneficiary receives a settlement, judgment, award, or other payment. In other words, following its September webinar featuring the CRC, CMS is now highlighting the work of its Benefits Coordination and Recovery Center (BCRC). The announcement can be found here.

Per the announcement:

The primary intended audience is attorneys who represent beneficiaries and other beneficiary representatives. The BCRC will present a refresher on the beneficiary recovery process, including what functions can be facilitated using the Medicare Secondary Payer Recovery Portal (MSPRP). Such functions include submission of authorizations, requesting a Final Conditional Payment, and electronic payments. The webinar will also discuss alternative demand calculation options (Self-Calculated Conditional Payment Amount and Fixed Percentage Option), as well as other beneficiary recovery tips and best practices. The presentation will be followed by a question and answer session with participants.

We encourage anyone who is new to Medicare conditional payment recovery through the BCRC or would like, as CMS indicates, a refresher, to attend the webinar.

If you have any questions regarding these announcements, please contact Tower’s chief compliance officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.

$750 Medicare Conditional Payment Recovery Threshold Remains for 2021

CMS Introduces Pre-CPNs and Open Debt Reports in Conditional Payment Recovery Process

New Ransomware Attack Threatens Healthcare Sector

October 30, 2020

threatening hooded figure with the word cyber security superimposed to illustrate post on best practices for cybersecurity

Tower’s cybersecurity partners, Avertium and Vigilant, have advised us of a major ransomware attack, primarily targeting the healthcare sector. The threat actor, known as “Ryuk,” uses phishing e-mails to gain access and then control of the victim’s computer and ultimately the company’s network. Once in control, files are encrypted and only decrypted in exchange for a “ransom.”

Avertium sent Tower this joint cybersecurity advisory from the Cybersecurity and Infrastructure Security Agency (CISA), the Federal Bureau of Investigation (FBI), and the Department of Health and Human Services (HHS) detailing a resurgence of this threat. Avertium also provided its cyber intelligence report which includes information on the attack and preventive measures.

Tower’s Response to Ransomware Threats

As a company that works directly with the healthcare sector, protection of our client’s information is critical to our Medicare Secondary Payer compliance services. Consequently, upon receiving the report of the Ryuk threat we immediately contacted our cybersecurity partner, Vigilant Technology Solutions, to confirm protections are in place to counteract any threats to Tower’s system.

Vigilant assured us that cybersecurity best practices are in place. First, its CyberDNA solution actively monitors Tower’s data traffic 24/7 and responds to threats in real time. Second, our network-installed McAfee Endpoint Protection (MEP) identifies a potential threat as early as possible and prevents the threat from entering the network or database. Third, our IT pros have previously taken the following recommended actions to keep customer data secure:

Ensure MEP is fully deployed to all applicable/at risk assets within your environment
Provide security awareness communications to employees as a reminder to be mindful during day-to-day activity:
- Never open unsolicited emails and their attachments.
- Be wary of suspicious looking advertisements.
- Limit / avoid the use of personal email on company assets.
Regularly update infrastructure (both operating system and application software) with the latest patches to ensure full coverage in addition to updated McAfee Anti-Virus software.
Ensure backups of data/records are regularly performed and available.

We urge our clients to confirm the above preventive measures are in place for their own network security.

For more detailed information on preventing ransomware attacks, CISA provides an updated guide which can be found here. If you have any questions regarding Tower’s cybersecurity program, please contact Jesse Shade, VP of Information Technology at jesse.shade@towermsa.com or 888.331.4941.

WEBINAR – Grasp Success in Settling Work Comp Cases

October 28, 2020

banner promoting Tower webinar on settling work comp cases

Seeking the formula for success in settling work comp cases with Medicare Set Asides (MSAs)? We’ve got you covered.

A Chinese proverb says, “The temptation to quit will be greatest just before you are about to succeed.” For workers’ compensation practitioners case closure represents success. However, the impediments presented by the need for an MSA to close a case often are a temptation to quit when success is within your grasp.

On Thursday, November 18 at 2:00 PM ET, Tower’s Chief Operations Officer, Kristine Dudley and Chief Compliance Officer, Dan Anders, will be joined by special guest, Nicole Chapelle, VP of Settlement Solutions for Ametros, to provide the formula for success in settling work comp cases with MSAs.

Here’s just some of what you will learn:

The latest on ways Medicare makes CMS MSA approval difficult or drives up MSA costs and how to meet these challenges.

Straightforward clinical interventions and case settlement strategies which reduce the MSA amount and allow for quick CMS MSA approval.

Easing the settlement concerns of the injured worker by transitioning to MSA professional administration or self-administration assistance for future medical care.

You will also learn that all of this can be done without increasing your work in successfully resolving the case.

A Q&A session will follow the presentation. Please click the link below and register today!

Dan Anders in WorkCompWire: Getting Real Value Out of Your Medicare Set Aside

Need a Medicare Set Aside Second Opinion?

October 27, 2020

nurse conducting research for a Medicare Set Aside Second Opinion in a manual

Has a Medicare Set Aside ever disrupted one of your settlements? Any one of these things — unexpected medical, surgical or pharmacy costs, compliance issues, the way MSA administration will be handled, or the presence or absence of a structured settlement–can halt negotiations.

Tower addresses cost drivers and deals with compliance situations long before preparing an MSA, so our clients don’t have to worry about MSAs impeding settlements and injured workers can be assured that their future medical needs will be met .

However, recently we’ve been asked to review MSAs prepared by other companies and found significant cost drivers and other obstacles to settlements. Fortunately, our free Medicare Set Aside Second Opinion service saved the settlements and helped to secure claim closures.

Medicare Set Aside Second Opinion Case Study

Here’s one case. Based on her experience with managing a claim and its costs, an adjuster thought the $220,000 MSA produced by another MSP provider was too high and asked us to review it.

Following our standard workflow for new MSAs, our Intake Team compared the MSA’s “accepted body parts” against the client’s claim system and found significant discrepancies.

The MSA allocated for a lifetime’s supply of sertraline, a drug used to treat anxiety and depression. However, “psyche/stress” was not an accepted body part and the workers’ comp insurer had not been paying for it.

Tower drafted a Body Part Letter that clarified the compensable conditions and specified those that were not accepted by or paid for by the insurer. Removing the drug from the allocation saved more than $58,000.

This 2^nd Opinion review also detected recommendations for inappropriate medical treatment, including an unnecessary bladder surgery. Our Physician Follow Up Service – available at no extra cost to our clients – contacted the physician and obtained written confirmation of this, reducing the allocation by another $37,000+. We also obtained a rated age from K.P. Underwriting that further reduced the treatment and prescription cost over life expectancy. The total savings came to over $98,000.

MSA Value is in Claim Closure

How could we do this when the other provider couldn’t? It comes down to our philosophy and attitude.

Tower does not treat MSAs as commodities. Instead, we recognize that the real business value of an MSA is in its ability to facilitate claim settlement and closure.

Our role is to collaborate with clients to analyze and assess risk, review medical and pharmacy records to determine Medicare exposure, intervene when treatment changes are needed, and recommend the appropriate time to complete the MSA.

In short, we proactively work to reduce costs and posture files for settlement.

How We Achieve Settlement Success

We created MSA best-practices technology and continually update it to make sure we can always accurately allocate the MSA without overfunding. Our MSP Automation Suite contains the very latest CMS coverage, coding and individual state pricing data. We measure everything and analyze CMS responses line by line so we know what the agency will accept, what it won’t and when to push.

We know where cost drivers tend to hide, and our Intake and Clinical Teams are trained to hunt them down. We know which interventions to apply at the right time to reduce costs. We know how to phrase treatment and pharmacy changes and supply the precise documentation CMS needs to approve the MSA.

And we do all this the first time around, so you won’t need a second opinion.

With Tower, payers can enter settlement negotiations with realistic MSAs that they can explain and defend. (We’ll participate in these negotiations if you’d like.)

Settle well the first time with Tower. But, if you have a questionable MSA, let us give you our free 2^nd opinion. Download more information here or refer an MSA for a 2^nd Opinion by contacting our Intake Team at 888-331-4941 or referrals@towermsa.com.