rita.wilson, Author at Tower MSA

Enhanced Portal Functionality for Final Conditional Payment Process

November 10, 2015

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

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

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

How the NGHP recovery process works today

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

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

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

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

2. CRC searches Medicare records for claims paid by Medicare

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

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

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

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

4. Applicable plan submits a dispute

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

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

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

The beneficiary’s name and Medicare Health Insurance Claim Number (HICN);
Date of accident/incident;
A claims listing of all related claims paid by Medicare for which Medicare is seeking reimbursement from the applicable plan; and
The total demand amount (amount of money owed) and information on administrative appeal rights.

If the CRC agrees with disputes submitted timely, unrelated claims will be removed from the case before the demand letter is issued. Please note that the demand letter may include related claims that Medicare paid after the CPN was issued. Relatedness disputes on all claims included in the demand letter may be addressed by submitting an appeal.

6. Applicable plan submits an appeal

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

7. Applicable plan submits payment

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

Facilitating timely and more accurate final demands

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

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

Closed Formularies Hold Promise for Workers’ Compensation Pharmacy Management

October 12, 2015

Opioids linked to escalation in claim cost

With the signing of A.B. 1124 by Governor Jerry Brown October, California has now joined a handful of states that have adopted closed pharmaceutical formularies in their workers’ compensation systems. While many details have yet to be worked out, the decision comes as good news for injured workers and payers alike.

Closed formularies essentially use evidence-based medicine to identity the prescription drugs that should be allowed for certain injuries. All other medications must go through a preauthorization process. The idea is to ensure the injured worker gets the right medication at the right time for the right reasons – AND to reduce unnecessary pharmacy costs.

Implemented appropriately, a formulary can result in better outcomes and lower costs. In fact, a study last year suggested California’s workers’ compensation system could save between $124 million and $420 million annually by adopting a formulary similar to that in effect elsewhere.

In addition to the states that have already implemented closed formularies or are in the process of doing so, several others are considering the idea. The result could be better efficiencies and significant savings for Tower MSA Partners’ clients in managing workers’ compensation claims even before the Medicare Set Aside review and triage process.

The specifics

Under A.B. 1124, the administrative director of California’s Division of Workers’ Compensation must create a formulary by July 1, 2017 for medications prescribed to injured workers. Between now and then, California regulators must determine a program that best addresses the needs of California’s injured workers.

Four states – Ohio, Oklahoma, Texas and Washington have implemented closed drug formularies. Arizona, Arkansas, California, Louisiana, Maine, Michigan, Montana, Nebraska, North Carolina and Tennessee are among the other states considering the formularies or in the midst of developing them.

There are several different types of formularies in effect. Washington, which adopted the first such formulary in 2004, has a more restrictive program than those in some other states. Texas, on the other hand includes more therapeutic groups and more choices within each group.

Regardless of the type of formulary, the states have touted successes. Texas, Washington and Ohio have all reported lower costs.

Texas, which implemented its closed formulary for new injuries in September 2011 and for all injuries in September 2013, also reported the number of injured employees receiving ‘N’ drugs – those requiring preauthorization – fell 65% and costs dropped 83% for new claims for injuries suffered on or after Sept. 1, 2011. Also important, the formulary has led to a significant reduction in the number of injured workers taking opioids on a long-term basis.

The Ohio Bureau of Workers’ Compensation likewise reported significant utilization and cost declines, including a 74% drop in skeletal muscle relaxants, a 25% decline in narcotics and a total drug cost drop of 16%, for a total of $20.7 million, in fiscal year 2014 compared with fiscal year 2011.

Many decisions must be made before California’s formulary takes effect and a variety of issues must be addressed. For example, the pre-approval process for drugs not allowed, decisions about the strategy for long-time opioid users, and considerations of compound medications must be determined.

Fortunately, a team of workers’ compensation stakeholders involved in helping to craft the legislation ensured some important provisions were included. The law requires the California Division of Workers’ Compensation to update the formulary at least quarterly, establish an independent pharmacy and therapeutics committee, accept public comment and publish two interim status reports

Supporters are confident when all is said and done, California’s formulary will provide effective treatment for injured workers, reduce delays and medical disputes, and reduce costs.

How closed formularies impact claims and MSAs

Closed formularies can serve as a gatekeeper in preventing troublesome medications being prescribed to injured workers. Medical providers in states with closed formularies tend to change their behavior and prescribe more clinically appropriate medications and treatments rather than unnecessary opioids and other drugs that require preauthorization.

While providers need approval to be reimbursed for medications not automatically allowed, supporters say closed formularies do not seek to prevent injured workers from having access to medications that are truly beneficial to them.

Workers’ compensation payers can also look for less adversarial relationships with providers, since there will be fewer questionable medications prescribed for the injured worker. Drugs that are not appropriate for first line therapy are generally those that are not allowed without prior authorization, under the closed formularies.

Many steps must be taken before California’s closed drug formulary will take effect and the devil is surely in the details. However, the fact that the nation’s largest workers’ compensation market is going in this direction is good news indeed!

Changes Afoot For Medicare’s Conditional Payment Reimbursement Process

September 5, 2015

Expect potential changes in the Medicare’s conditional payment reimbursement process related to a workers’ compensation claim while the claim is still open, possibly more than once. That is among the changes stemming from a revised process to seek reimbursement of conditional payments made in a claim.

Beginning Oct. 5, Medicare is shifting responsibility for its recovery of conditional payments, where the Centers for Medicare and Medicaid Services (CMS) is pursuing recovery directly from a workers’ compensation entity, to the Commercial Repayment Center (CRC), away from the Benefits Coordination & Recovery Center (BCRC). The transition will result in several changes to the process.

Working with the experts at Tower MSA Partners means your claims professionals need not be experts on Medicare Secondary Payer (MSP) compliance or conditional payments. However, payers should be aware of the new process and take steps to reduce any challenges.

Medicare’s Conditional Payment Reimbursement Process: The Plan

The move by CMS for reimbursement recoveries from non-group health plans to the CRC follows CMS’ previous transition of group health plan recoveries. In addition to workers’ compensation entities, the change will also pertain to CMS’ recovery efforts directly from a liability insurer (including a self-insured entity) and no-fault insurer.

The transition will only affect new conditional payment recovery efforts. Actions pending prior to the transition will continue to be managed by the BCRC. The BCRC will also continue to handle recoveries when a beneficiary self reports that a workers’ compensation or other non-group health entity has primary payment responsibility for a claim where Medicare has made a conditional payment.

CRC will manage cases where the Responsible Reporting Entity (RRE) has reported Ongoing Responsibility for Medical (ORM), ORM Termination or Total Payment Obligation to Claimant (TPOC) on Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) and CMS has identified the primary debtor as the RRE.

Changes

One of the biggest changes is in the initial dispute process. Where the BCRC provides a Conditional Payment Letter (CPL), the CRC will issue a Conditional Payment Notice (CPN). Both are information — not requests for payments. Both identify the amount of the current conditional payment, provide a statement of reimbursement, and describe the manner for disputing the charges.

However, where the CPL has no specific date for a response, the CPN must be disputed within 30 days. Failure to do so will result in a demand letter or initial determination issued to the applicable plan for payment. While applicable plans do have appeal rights for recovery demand letters issued on or after April 28, 2015, the demand letter locks the applicable plan in place as the identified debtor. Also, interest accrues from the first day of a demand letter; however it will not be assessed if the debt is paid within 60 days.

The CRC will begin to issue CPNs starting October 25, from Section 111 data processed on or after October 5. A CPN is typically issued when an applicable plan reports under Section 111 that it has ORM or a responsibility for the claim as a primary payer, rather than when a settlement, judgment or award is issued.

To dispute the CPN, the applicable plan may contact the CRC in writing or through the Medicare Secondary Payer Recovery Portal (MSPRP). However, disputes submitted through the portal may only be on the basis of relatedness and in response to a CPN. All other disputes must be in writing.

Applicable plans will have one opportunity to file a dispute. If the CRC does not agree with the dispute, the conditional payments will be reflected in the demand letter.

What you can do

Workers’ compensation payers can help prepare for a smooth transition by taking the following actions:
• Carefully review all correspondence related to conditional payments to determine if they are generated by the CRC or BCRC.
• Develop and implement a process for the timely review of CPNs as well as CPLs.
• Make sure disputes of CPNs are properly filed within the 30-day time limit.
• Ensure Section 111 reporting information is updated.
• Make sure the ORM process is working properly.

More specific details will follow as we track the rollout of this process…. Stay Tuned!

What Can Data Tell Us About Predictors of Long Term Opioid Use?

July 9, 2015

Virtually every day, I encounter an MSA where the use of opioids has affected not only the cost of settlement, but has impacted quality of life, and even reduced life expectancy as a result of the side effects that often occur with long term opioid use. In each situation, I find myself asking the same question, “Could this have been avoided?” I want the answer to be a resounding “YES”, but when I look at the history of the claim, I find so many different paths taken through the years of treatment, it’s difficult to find the single turning point that took both patient and claim in the wrong direction.

Today I ran across a study that reminded me of a basic problem solving pillar I learned from my early IT days.

When troubleshooting a logic problem, shortcuts rarely work. We must go back to the beginning.

Back to the Beginning

In a recent article published by the Mayo Clinic, a team of researchers headed up by anesthesiologist, Dr. Michael Hooten, studied how many patients prescribed an opioid for the first time progressed to long term prescriptions, even to the point of addiction. The answer: 1 in 4 people. In its findings, the researchers noted that people with histories of nicotine and past substance abuse were likeliest to use opioid pain medications long term.

Researchers used the National Institutes of Health-funded Rochester Epidemiology Project to get a random sample of 293 patients who received a new prescription in 2009 for a short acting opioid pain medication such as oxycodone, morphine, hydromorphone, oxymorphone, hydrocodone, fentanyl, meperidine, codeine and methadone. In their analysis, they found that 21 percent, or 61 people, progressed from short-term use to prescriptions lasting three to four months, and 6 percent, or 19, of the 293 studied ended up with more than a four-month supply of the drugs.

What’s the Connection?

According to Dr. Hooten, it’s “all in our heads”. The actual truth is that neurobiology related to chronic pain, chronic opioid use and addiction is similar. We know that smoking has complex effects on pain perception in humans and has long been considered a risk factor for a number of painful conditions, including low back pain and musculoskeletal pain. There have also been behavioral animal studies (Vihavainen T, Piltonen M, Tuominen RK, Korpi ER, Ahtee L., Eur J Pharmacol. 2008) that have shown that both the rewarding and the psychomotor-activating effects of morphine were enhanced following nicotine treatment. Basically, according to Dr. Hooten,

Nicotine activates a group of receptors, or brain structures, in a way very similar to how opioids and chronic pain may activate them.

Impact On Early Treatment

According to Dr. Hooten, the identification of nicotine use and substance abuse as top risk factors for long-term use of opioids suggests that physicians should be particularly careful about prescribing these pain medications to patients with such histories. For workers’ compensation, however, it is critical to identify the potential risk factors before opioid medications are approved the first time, and if possible, even before the patient sees the physician.

Asking the Right Question

If potential risk factors such as past substance abuse and nicotine use could be obtained through investigative data gathering during the first 72 hours after an injury, is there an opportunity to mitigate exposure, and to optimize claim, patient health and settlement outcomes?

With more access to data via social media investigations, employment and medical history searches , financial / credit checks and general post-injury questioning, early claim data analytics can be a tremendous tool to identify triggers that could indicate future claim complications.

FDA Approves Generic Release of Abilify

May 1, 2015

The U.S. Food and Drug Administration (FDA) approved the first AB-rated generics to Bristol-Myers Squibb and Otsuka’s Abilify® (aripiprazole) tablets, an atypical antipsychotic drug commonly used for treating schizophrenia and bipolar disorder. The agency approved generics from Alembic Pharmaceuticals, Hetero Labs, Teva Pharmaceuticals and Torrent Pharmaceuticals. At least one manufacturer, Teva, announced the launch of its generic in the currently marketed strengths of 2mg, 5mg, 10mg, 15mg, 20mg and 30mg tablets.

Specifics of Release

Brand Name: Abilify® (aripiprazole – Bristol-Myer’s Squibb/Otsuka)
Indication: Treatment of schizophrenia, acute treatment of manic and mixed episodes associated with bipolar I disorder, adjunctive treatment of major depressive disorder, treatment of irritability associated with autistic disorder and treatment of Tourette’s disorder.
Generic Manufacturer(s): Alembic Pharmaceuticals, Hetero Labs, Teva Pharmaceuticals and Torrent Pharmaceuticals
Launch Date: April 28, 2015

Potential Obstacles and Alternatives

Teva’s launch is considered “at risk” due to ongoing litigation over three later listed patents in FDA’s Orange Book covering Abilify. The other manufacturers have not yet announced the launch of their generics.
Other atypical antipsychotic medications include Clozaril® (clozapine – Novartis, generics), Fanapt™ (iloperidone – Vanda), Geodon® (ziprasidone – Pfizer, generics), Invega™ (paliperidone – Janssen), Latuda® (lurasidone– Sunovion), Risperdal® (risperidone – Janssen, generics), Saphris® (asenapine – Merck / Actavis), Seroquel® (quetiapine – AstraZeneca, generics) and Zyprexa® (olanzapine – Lilly, generics).

The Good, the Bad and the Ugly

The good….As an expensive brand medication commonly prescribed in workers’ comp for off label use for depression and sleep related issues, the release of generic Abilify® (aripiprazole) tablets is certainly a welcomed event for our MSA submissions.
The bad….We know from past history that price concessions during the initial generic release period are normally no more than 10-12% off the original brand AWP (average wholesale price).
The ugly… We also know from past history that as one brand moves to generic, soon to follow are new and even more expensive alternatives. Two new atypical antipsychotic drugs are currently under FDA review. Actavis’ cariprazine could be approved during the second quarter of 2015. Brexpiprazole, Otsuka’s follow-on to Abilify, has an FDA action date of July 11, 2015.

Impact on CMS Review of WCMSAs:

Abilify is an expensive medication used off label by many physicians in workers’ comp. As such, it is consistently identified as a medication trigger in our pre-MSA review and triage process. When possible our team of physicians attempt collegial dialogue with the treating physician to discuss the nature of the injury and causal relationship with psych conditionals, and to specifically discuss the rationale behind off label use of Abilify.

According to ODG (Official Disabilities Guideline), Abilify is a ‘N’ drug (as are all atypical anti-psychotic medications), meaning it is not appropriate for first-line therapy. This is how Medicare views Abilify, and why it’s critical to address Abilify’s use before it shows up as treatment on an MSA. As an ‘N’ drug, Ability should go thru a pre-authorization process where the prescriber justifies its use before being dispensed through the PBM.

For questions about Abilify, its generic release, its use in WCMSAs, both FDA approved and off label uses, please contact us @ info@towermsa.com or 888-331-4941.

CMS Releases Updated WCMSA Reference Guide v2.3

January 12, 2015

On January 6, 2015, CMS released an updated version of the WCMSA Reference Guide (COBR-Q1-2015-v2.3). A complete list of the changes can be found in Section 1.1 (p. 7) of the Guide and include language changes and clarifications as follows:

Corrected reference from 42 CFR 411.46 to Section 1862(b)(2) of the Social Security Act.
Clarified reference to costs related to the workers’ compensation claim, rather than the compensable injury.
Clarified reference to future medical items and services as “Medicare covered and otherwise reimbursable.”
Clarified that CMS approves the WCMSA amount, not the WCMSA, upon submission of a request.
Correspondingly, clarified language referring to submission of a proposed WCMSA amount, rather than a WCMSA proposal.
Restated the comparison of fee-schedule vs. full-and-actual-costs pricing as the basis of pricing the proposed amount, rather than the basis of payment from an approved WCMSA account.
Clarified attestation vs. accounting wording.
Clarified procedural results when Medicare is not provided with information in response to a development request.
Removed the word “form” from references to documents that are not forms.
Added language to address schedule change for hydrocodone compounds from schedule III schedule II. See Section 9.4.6.2.
Changed deadline for responding to development requests for submission through the WCMSA Portal to 20 from the previous 10 days. See Sections 9.4.1 and 9.5.

What’s the Significance?

Of the updates noted above, the only items of significance to those who interact with CMS on a daily basis, are the last two changes listed – language changes as a result of the reclassification of hydrocodone to Schedule II, and the extension of the deadline for responding to development requests.

Reclassification of Hydrocodone

As documented in Section 9.4.6.2, Hydrocodone products now require new prescriptions at intervals of no greater than 30 days, however, a practitioner may issue up to three consecutive prescriptions in one visit, authorizing the patient to receive a total of up to a 90-day supply of a C-II prescription. For all new cases submitted after January 1, 2015, the WCMSA guidelines require allocation of a minimum of 4 healthcare provider visits per year when schedule II controlled substances (including hydrocodone combination products) are used continuously, unless healthcare provider visits are more frequent per medical documentation.

The allocation of 4 physician visits per year for ongoing monitoring has been a standard CMS response trend for more than a year, and is commonly seen for long term pain management. What is different here, and of potential concern, is the final statement “unless healthcare provider visits are more frequent per medical documentation.” We have seen a recent CMS response trend in which 12 physician visits per year were allocated when medical records indicated that the patient was seeing a healthcare provider monthly, even if only to obtain prescriptions. With the number of patients taking hydrocodone, and the April 5, 2015 cutoff for hydrocodone refills (6 months after the October 5, 2014 reclassification), is it possible that adjusters may see an increase in the number of office visits?

When long term use of hydrocodone products exists and patients are seeing healthcare providers at more than a 90 day frequency, with office visits only to obtain new prescriptions, adjusters should be aware that this practice may have a negative impact on the number of physicians allocated on the MSA. As part of the Tower MSA Partners pre-MSA review process, the issue of office visit frequency is identified as a potential cost driver and efforts are made to leverage the 90-day prescription authorization and reduce the number of office visits documented in the medical records before finalizing the MSA. This will ensure that CMS will respond with no more than the published 4 visits per year.

20 Day Deadline for Development Requests

According to the WCRC, the five most frequent reasons for development requests include the following:

Insufficient or out-of-date medical records (CMS requests current payout and will expect all associated medical records).
Insufficient payment histories, usually because the records do not provide breakdown for medical, indemnity, or expenses categories;
Failure to address draft or final settlement agreements and court rulings in the cover letter or elsewhere in the submission;
Documents referred to in the file are not provided—this usually occurs with court rulings or settlement documents;
Submissions refer to state statutes or regulations without providing sufficient documentation, i.e., a copy of the statute or regulation, or notice of which statutes or regulations apply to which payments.

Regardless of the date of the completion of the MSA, Tower’s pre-CMS submission process will include a review of all recent treatment records to ensure that the allocation accurately reflects current treatment and up to date prices. We also look for gaps in treatment that could result in CMS requests for primary care physician records. When identified, we attempt to address this before CMS submission, providing the necessary documentation in the MSA to mitigate development requests and slower CMS turnaround times.

Conclusion

Tower will continue to benchmark CMS response trends externally, as well as measure internal submission / response accuracy and inclusion by evaluating each procedure, service and medication against CMS’s response frequency and price, acknowledging that we do not seek 100% CMS acceptance. Our goal is to proactively identify and address cost drivers before CMS submission, to provide clear documentation of optimized treatment, and to prepare an MSA that appropriately protects Medicare’s interest.

New Additions to Tower Executive Team

August 13, 2014

In our continued commitment to build a unique MSP compliance model focused on identification, intervention and involvement to stage claims prior to MSA and settlement, I am pleased to announce the addition of two key individuals to the Tower MSA Partners executive team.

Scott E. Yasko, MBA

Scott joined tower in July to serve as EVP, Business Development. In his new role Scott is responsible for management of sales and marketing activities for all products and service offered by Tower. Prior to joining Tower, Scott served in a sales and marketing capacity at PRIUM, a medial cost management firm with focus on prescription drug misuse and above within the workers’ compensation industry.

As an expert in the arena of pharmaceutical knowledge and the impact of drug misuse on workers’ compensation claims, Scott plays a strategic rol in Tower’s pre-MSA intervention model, a key differentiator for the company in the MSP compliance arena.

Holly Neary, RPh

As Director of Clinical Services, Holly will oversee all aspects of the company’s Pre-MSA review and intervention services, as well as serving as client and physician liaison for issues related to inappropriate medication use, particularly as it relates to the long term use of opioids to manage chronic pain.

Prior to coming to Tower, Holly spent the previous 14 years serving in various capacities of pharmacy management within retail and compounding pharmacies. In her role as manager, Holly’s strength throughout her career has been work flow optimization and streamlined processes, balancing expertise with personal attention in an effort to deliver appropriate prescription solutions through drug utilization review. Holly also served as clinical specialty pharmacist with United Health writing guidelines for Medicare and Private Insurance plans.

Tower is fortunate to have two such talented individuals to help guide our future.

Chronic Pain Can Be Managed With Alternative Therapies

July 10, 2014

Traumatic injuries and opioid therapy can alter the pain pathways in the central nervous system, and this process is called neuroremodeling. This can cause unwanted or undesirable reactions to pain and negatively impact the recovery process. There are several approaches to reversing the neuroremodeling, some of these alternative treatments include cognitive behavior therapy and opioid tapering.
A patient cannot overcome chronic pain when their mind is at odds with their body, and so psychological therapy can be an effective way to reverse the body’s perception of pain. Cognitive behavior therapy uses teaching strategies to enable patients to control their perception of pain, and to overcome the feeling of defeat about an injury. Through CBT, patients learn to cope with existing pain using relaxation, distraction, imagery and self-hypnosis.

Chronic pain affects the whole person… mind, body and spirit. As such, pain management alternatives must consider more than just the physical.

“In some patients, opioid therapy administered to reduce pain has the opposite effect and the patient experiences an increased feeling of pain. This effect is called opioid-induced hyperalgesia (OIH). OIH is an example of neuroremodeling that occurs to the specialized receptors in the body that respond to opioids. The cause is unknown, but sometimes a normal perception of pain can be restored by discontinuing opioid therapy through a medically supervised program. The assistance of a comprehensive pain management center experienced in opioid tapering may be necessary.”

— Read More At WorkCompWire

Managing Costs Of The Aging Workforce In Workers’ Comp Claims

Problems arise in the workplace with aging employees, especially when the work involved requires physical stamina. The same can be said for those employees with pre-existing medical conditions, like diabetes or asthma. One way to manage the occurrence of workers’ compensation claims is to provide a number of alternatives for employees, measures that will act as preventative care.

Some companies determine the definition of aging by setting a certain age limit, depending on the type of work it can be as early as 35. While it has been shown that there are no greater instances of workers’ compensation claims in older workers, the cost of claims from aging workers is significant to companies. Implementing wellness programs that provide incentives for healthy behavior is one way to counter the aging or ailing of your workforce. Marsh has released a Risk Management Research Briefing that shows ways in which employers can counter the workers’ compensation costs for an aging workforce.

The cost to employers when older workers are injured can be much higher than when younger employees are injured. Obesity and other comorbidities common to older employees could also extend recovery times. But you can take action to reduce the frequency of injuries and help your employees remain fit and better able to recover following an injury.

— See More At WorkCompWire

Is The Tidal Wave of CMS Development Letters Behind Us?

May 14, 2014

In case you didn’t hear us shouting from the rooftop, Tower MSA Partners (as well as other companies across the MSA industry) was notified Tuesday, May 13, 2014 that full MSA approval had been given for approximately 100 cases, more than 50 of which were in various stages of development request processing. While this was certainly a welcomed announcement, I believe strongly that it was not an arbitrary decision by CMS, nor was it achieved by a few large companies. I see this accomplishment as the result of the combined and focused efforts of many in the MSP compliance industry.

Where Do I Begin?

As many of our clients have become painfully aware, development requests have been a major issue for Tower, as well as every carrier, employer and MSA provider in our industry, since late 2013. In early January, I discussed this new trend via a blog article (http://www.mspcomplianceblog.com/cms-wcrc-development-letters-essential-information-or-delay-tactic/ ) to explain what we were seeing as a company. In follow up to the article, I took this information to my industry peers, encouraging their participation to track the trend through my involvement with the Data and Development Committee of NAMSAP (National Alliance of MSA Professionals).

An Industry Moved to Action

Data capture of development requests began in January with analytics by the DDC for the next 90 days. At the same time, the NAMSAP Board of Directors asked that I prepare an article to be published in NAMSAP’s national newsletter, and also to help author a letter to be submitted to CMS on behalf of the NAMSAP BOD. The article’s intent was to communicate the source and impact of development letters among our membership, and to encourage readers to share their experiences in the form of actual data. The letter to CMS presented aggregated, experiential data to demonstrate the effects of the WCRC’s actions, and to communicate the settlement obstacles being created by this process (not the least of which was the request for HIPAA protected primary care physician medical records).

Communication Through Data Analytics

Through the efforts of the DDC to summarize the data obtained from multiple companies across our industry, the letter submitted by NAMSAP’s BOD to CMS provided clear evidence of the impact of the actions of the WCRC on settlement initiatives. We then requested that CMS work with our industry to reestablish a strategy that included only ‘injury related’ medical and pharmacy history, and followed the published standards defined in the March 2013, November 2013 and February 2014 editions of CMS’s own WCMSA Reference Guide as their only criteria to ensure that Medicare’s interests are adequately protected.

While we cannot confirm that CMS’s recent actions were in response to the initiatives pursued by NAMSAP, or through the efforts of a single company, we certainly believe industry involvement for the benefit of all stakeholders was the right course of action and are thrilled with the outcome. We are pleased to have been an active participant in this process.

Lessons Learned?

As the MSP compliance partner for employers, TPAs and carriers, our primary responsibility is to prepare and submit Medicare Set Asides that to the best of our knowledge, ability and expertise ensure that Medicare’s interests are adequately protected when settling future medical claims. From a professional ethics perspective, this means doing what is reasonable on behalf of the claimant. For Tower, we describe this as, “helping clients balance care, cost and compliance when settling claims that involve Medicare beneficiaries”.

One of our client’s website taglines reads as follows, “We strive to ensure that injured workers get the right care at the right time—and we focus on getting it done the right way. It’s our commitment.” I’ve read this quote many times and strongly believe this is the goal of most in our industry….. do what is reasonable. And in the end, regardless of CMS submission and approval, I believe this will provide adequate evidence of our efforts to protect Medicare.

Looking ahead, we must now prepare our team and our clients for the next wave of CMS submissions. How do the experiences of the past 6 months impact our internal processes going forward? Was the development letter barrage truly a ‘ghost hunt’, or is there something to be learned from the WCRC’s actions? This will be the focus of our attention in the coming weeks.