MSP Compliance Blog

Expert summary, analysis and recommendations on issues impacting Medicare Secondary Payer compliance.

Post-Settlement Care, Cost and Compliance Through Professional Administration

Posted on December 6, 2022 by Tower MSA Partners

While workers’ comp payers invest considerable resources to manage and settle claims, they don’t always prepare Medicare-eligible injured workers for life after settlement. These patients have usually been in the workers’ comp system for several years. And the system has paid for their injury’s treatment and medication, and in some cases, coordinated their care.

When their claim closes, all that comes to an end. Injured workers are on their own to navigate the healthcare system and handle the bills. They need to pay for doctors’ visits and medication from their Medicare Set-Asides (MSAs). They also need to make sure Medicare doesn’t have to pay for their injury-related care. Post-settlement compliance responsibilities can be overwhelming.

Tower’s recent Premier Webinar: Care, Cost & Compliance Through Professional Administration featured Nicole Chappelle who has nearly 30 years’ experience in all aspects of claims management — before and after settlement. Now Vice President of Settlement Solutions for Tower’s partner Ametros, Nicole joined our Chief Compliance Officer Dan Anders for what could be our liveliest webinar yet.

Here are some takeaways:

  • Injured workers who are also Medicare beneficiaries can self-administer their MSA or use professional administration.
  • The Centers for Medicare and Medicaid Services (CMS) highly recommends professional administration for beneficiaries who take opioids and other frequently abused controlled substances.
  • Professional administration is available for MSAs that are CMS-approved and for those that are not submitted for CMS approval.
  • Payers typically cover Ametros’ one-time professional administration fee of $1,000.

Although CMS allows beneficiaries to self-administer an MSA, it strongly recommends they consider professional administration.  So do we.

First, MSA funds can only be used to pay for Medicare-covered medical treatment and prescription drugs related to the claim. Learning what Medicare does and doesn’t cover is challenging at best. It’s even more confusing for an injured worker whose workers’ comp program paid for items that Medicare does not cover, such as a sophisticated power wheelchair, home healthcare, and off-label use of certain medications. Will the typical, older injured worker understand this?

Additionally, MSA funds must be kept in an interest-bearing checking or savings account and used only for the aforementioned Medicare-covered care related to the claim.  Even the interest needs to be used for this purpose.

The administrator has to maintain itemized medical and pharmacy receipts, bank statements, and other records for each transaction from the MSA account. An attestation of these expenditures needs to be submitted to the Benefits Coordination & Recovery Center (BCRC) every year.

If the MSA is funded with an annuity and funds run out in any given year, the administrator must report the temporary exhaustion of funds to the BCRC. Should funds be permanently exhausted, the administrator needs to send the BCRC a final attestation letter confirming the situation.

If MSA funds remain when the beneficiary dies, the executor or administrator is to notify the BCRC and pay for outstanding (related) medical bills from the fund.  But would an executor know to do this?

Some things are best left to professionals.

If you’d like to see the whole webinar, please contact Dan Anders at daniel.anders@towermsa.com for the link and slides. He’s happy to connect you with Nicole Chappelle, too.  And, as always, if you have any questions about MSAs, post-settlement compliance, or other Medicare Secondary compliance issues, get in touch with Dan.

Related posts:

Study Shows Post-Settlement Medicare Treatment Denials Do Occur

Build a Better Tower: Partnerships Speed Settlements of Workers’ Comp Claims with Medicare Set-Asides (towermsa.com)

CMS Announces Upcoming Section 111 Webinar / WCMSA Reference Guide Update Released

Posted on November 15, 2022 by Daniel Anders

The Centers for Medicare and Medicaid Services (CMS) recently published a Section 111 reporting webinar notice and an update to its CMS WCMSA Reference Guide.

CMS Section 111 Reporting Webinar

CMS will hold a Section 111 NGHP Webinar on December 6, 2022, at 1:00 PM ET.  The notice says:

CMS will be hosting a Section 111 NGHP webinar. The format will be opening remarks by CMS, a presentation that will include NGHP reporting best practices and reminders followed by a question and answer session. For questions regarding Section 111 reporting, prior to the webinar, please utilize the Section 111 Resource Mailbox PL110- 173SEC111-comments@cms.hhs.gov.

The webinar notice can be found here.  We encourage anyone involved in the management of Section 111 reporting to tune into it.  Please note that there is no pre-registration; instead, the link and call-in phone numbers are on the notice.  You just log in shortly before the webinar’s start time.

WCMSA Reference Guide Update

The update to CMS’s WCMSA Reference Guide, Version 3.8 provides for changes to the re-review criteria. (Because CMS does not have a formal appeals process after an MSA determination, it allows what are called re-review submissions).  Currently, CMS allows for re-reviews for mathematical errors and missing documentation.  It has now added a section for submission errors which provides:

Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual. Note: This submission option is only available for approvals from September 1, 2022 forward.

  •  Examples include, but may not be limited to: medical records with incorrect patient identifying information or rated ages where the rated-age assessor provided incorrect information in the rated-age document.

Rather than applying to submitter errors, this addition to the re-review policy appears to account for errors in the documentation that was provided to the submitter, such as a rated age or medical records.

Tower conducts a thorough review of all relevant documentation when the MSA is prepared and submitted.  Consequently, documentation errors are identified and corrected before MSA submission.  As such, we expect to make minimal use of the Submission Error Re-Review.

CMS also added a new section entitled Re-Review Limitations:

16.2 Re-Review Limitations

 Note: The following re-review limitations are only available for approvals from September 1, 2022 forward.

 Re-review shall be limited to no more than one request by type.

 Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error.

 Re-review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.

It appears that the long-time policy of unlimited re-reviews has come to an end.  We understand CMS’s statement that a re-review “shall be limited to no more than one request by type” to mean one re-review is allowed for a mathematical error, one for missing documentation, and one for a submission error.

CMS’s intention for stating that a “disagreement surrounding the inclusion or exclusion of specific treatment or medications does not meet the definition of a mathematical error” is not clear.  While perhaps not a math error, when medical records from a treating physician clearly say surgery is no longer recommended or medication has been discontinued but CMS includes such treatment or medication in the MSA, we submit it as an error.

Tower has submitted numerous re-review requests to remove or modify treatment or medication from the MSA based on treating physician statements in the medical records.  Tower has a 68% success rate with re-reviews when CMS previously issued an MSA counter-higher, proof that these are reasonable requests. We hope the addition of Section 16.1 does not signal CMS’s intention to reject these reasonable re-review requests.

If you have any questions, please do not hesitate to contact Dan Anders, Tower’s Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

 

For the First Time, CMS Releases Key Metrics on WCMSA Review Program

Posted on November 9, 2022 by Daniel Anders

The Centers for Medicare and Medicaid Services (CMS) recently released data that provides insight into its Workers’ Compensation Medicare Set-Aside (WCMSA) reviews.  This is the first time CMS has released such detailed metrics.

CMS shared statistics for a 3-year period of 2020 through 2022 (CMS’s fiscal year ends on Sept. 30). The data compared proposed MSA amounts with the CMS-recommended amounts (what we typically call the “approved” MSA amounts).  The data can be found here.

 MSA reviews are down

In 2020 CMS completed 16,517 reviews and by the FY end of 2022, this had dropped to 13,752 reviews, a 17% decline.

The reason for the decline is up for speculation.  There may have been fewer settlements and thus fewer MSAs during the pandemic. However, NCCI’s data* show that claim frequency only declined by about 1% when 2020 and 2021 are considered together.

Another theory is that the reduction reflects a trend of settling parties choosing not to submit the MSA to CMS for approval.  Whatever the reason, there has been less engagement with the CMS WCMSA review program.

 Review Methodologies Remain Consistent

When CMS disagrees with a proposed MSA amount it issues a counter-higher with an amount it recommends for the MSA allocation.  The data provided by CMS show that the variance between total MSAs proposed versus recommended change was 13% (2020), 15% (2021) and 14% (2022). This consistency of result is because CMS’s WCMSA review methodologies have remained largely the same over the last several years.

Average Recommended MSA Is Steady

The year-over-year data show very little change in the average recommended MSA amount from $84,563.33 in 2020 to $81,571.75 in 2022.

 A Billion Dollars a Year

The CMS data show that the amount the agency consistently recommends for all the MSAs comes to over $1 billion annually.  However, this does not necessarily represent $1 billion in savings to Medicare.  Savings result when the MSA is funded in a settlement and the MSA funds are expended for injury-related medical care that Medicare would otherwise cover.

How Tower’s MSAs Stack Up

The release of these statistics gives us a unique opportunity to compare Tower CMS-approved MSAs against all CMS-approved MSAs.

Average CMS-Approved MSA (2021 numbers):

CMS:  $80,741                                                 Tower:  $54,956

Tower’s CMS-approved MSAs are 32% lower than the CMS average approved MSA

And if we isolate just the prescription drug component of the MSA.

Average CMS-approved Rx Amount in MSA (2021 numbers):

CMS: $20,916                                                  Tower:  $14,079

Tower is 33% lower than the CMS average for the prescription drug component.

These comparisons prove that Tower’s MSA allocation methodology along with our focus on cost mitigation through interventions, such as our Physician Follow-up service, reduce MSA allocations. Simply put, what this means to our partner clients is millions of dollars in savings.  These metrics also show that cost reductions can be obtained, even when payers choose the CMS MSA approval process.

The release of data on CMS programs has been a policy initiative of the National Medicare Secondary Payer Network (MSPN), to which Tower belongs. We are pleased that MSPN’s efforts have resulted in this release.

We also thank CMS for publishing these statistics.  Hopefully, it will become an annual report that includes more metrics on WCMSA reviews, such as the percentage of MSA proposals that are developed for information post-submission. It would also be interesting to learn how many MSAs are funded in a lump sum versus those funded via an annuity. In addition, MSPN is interested in metrics surrounding Section 111 reporting and Medicare conditional payments.

If you have any questions about this report or anything else on MSP compliance or MSAs, please feel free to contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

*See Rabb, W., (2022, May 11). “Claims Frequency Up for 2021, but Workers’ Comp Profitability ‘Unprecedented,’” Insurance Journal.

CIO Review Magazine Ranks Tower MSA Partners Among Top 10 Compliance Technology Services Companies

Posted on November 3, 2022 by Tower MSA Partners

The honors keep coming. Earlier this year, Tower ranked in South Florida Business Journal’s Top 25 Women-Owned Business list and now there’s national recognition of our technology driven compliance services. CIO Review: The Enterprise Technology Magazine just listed us among its 10 Most Promising Technology Compliance Services Companies for 2022 and featured Tower in this article.

When our Co-founders Rita Wilson and Kristine Dudley looked at the Medicare Set-Aside (MSA) landscape back in 2010, they found it littered with paper and inefficient processes. Everything was manual. Few providers tried to mitigate costs. And MSAs took so long to produce that some settlements fell through.

After talking with prospective clients to determine their pain points, Rita and Kristie knew they needed to accelerate MSA production. They automated Medicare Secondary Payer (MSP) compliance and MSA best practices into Tower’s MSP Automation Suite.

Because the suite easily integrates with any claims system and gathers data needed to prepare the MSA, it immediately reduced payers’ administrative burden. For the first time, clients also had 24/7 visibility into the entire claim. They could pull reports and check the status of an MSA anytime.

The suite also prompts for next steps and missing data to help keep claims moving. MSAs can be produced in days instead of weeks.

Tower’s MSP Automation Suite was designed so modules could be easily added to quickly adapt to changes from the Centers for Medicare and Medicaid Services. For example, when the agency announced plans to impose high penalties for inaccurate or slow Section 111 Mandatory Insurer reporting, Tower built a dashboard to steer compliance efforts to help clients avoid these future penalties.

The technology helps us mitigate MSA costs and immediately implement CMS changes. It also makes compliance more efficient for Tower’s clients and employees.  It frees our professionals to concentrate on clinical and legal interventions to reduce allocations and focus on our clients.

One of our clients said,Tower MSA has been a great partner for us! I have been very impressed with their level of communication and availability to help answer questions. Their easy referral process and fast turnaround times are much appreciated.”

Naturally, we enjoy external validation from honors like the CIO Review recognition. But it’s a real honor to serve our client partners who are some of the most respected payer organizations in the industry.

We’re constantly looking for ways to improve, meet clients’ needs, and exceed their expectations. Please contact Rita Wilson, rita.wilson@towermsa.com with any questions, suggestions, or other ideas.

Premier Webinar: Care, Cost & Compliance Through MSA Professional Administration

Posted on October 25, 2022 by Tower MSA Partners

We rightly invest time to draft a Medicare Set-Aside (MSA) that accurately considers future medical care and, when appropriate, obtain approval of the allocation from the Centers for Medicare and Medicaid Services (CMS).

However, we don’t always dedicate enough time to address the MSA’s post-settlement implications for the injured or ill employee. This is a mistake. The comfort level the injured employee has with how well the MSA will be funded, its administration, and what resources are available to them after the claim closes often leads to their agreement to settle.

Tower MSA Partners is pleased to present this premier webinar on Nov. 16 at 2 PM ET which will feature special guest presenter, Nicole Chappelle, Vice President of Settlement Solutions for Ametros and Dan Anders, Tower’s Chief Compliance Officer.

The presentation covers:

  • CMS rules and options around MSA administration and MSA funding
  • Self vs. professionally administered MSAs
  • A step-by-step guide to how MSA professional administration works
  • Incorporation of MSA professional administration into a settlement agreement and expectations post-settlement

A Q&A session will follow the presentation, and you can provide questions you’d like us to cover when you register. Please click the link below and register today!

Register Here

For Media Inquires, Contact:

Helen King Patterson
813.690.4787
helen@kingknight.com

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