Posted on June 17, 2021 by Tower MSA Partners
Tower’s free Physician Follow-up service is one of our most effective tools for reducing your MSA costs. This case history offers a deeper dive on how we use this tool.
Physicians often need to try different medications as they search for the best way to manage pain, and medical records do not always show that drugs had been discontinued. That happened in a case where the initial Medicare Set-Aside exposure was $285,181.
Physician Follow-up Case Study
An injured worker suffered from low back pain along with significant pain in his groin, hip, and left knee. By the time it came to settle the case, he was seeing a pain management specialist and benefiting from oral opiates and injection therapy.
Tower’s review of his medical records detected Amrix, Celebrex, and Amitriptyline as potential unnecessary cost drivers. We recommended having our Physician Follow-up service contact the treating physician to confirm the current drug regimen and, if appropriate, document clarifications to the medical records.
First, our Physician Follow-up professionals determined that the drug regimen for the work injury was limited to oxycodone/APAP 5/325mg BID and three injections per year and that all other medications listed in the medical records had been discontinued. Then, following the state’s jurisdictional requirements, they drafted an attestation letter stating this and obtained the doctor’s signature.
By scrutinizing the medical records and properly wording and documenting the statement, Tower submitted an MSA of $53,664 to CMS. CMS approved the MSA within nine days with no development letter or counter-higher for a savings of $231,487.
Physician Follow-up is Comprehensive
Tower’s Physician Follow-up addresses open-ended, ambiguous and contradictory medical records and can replace a physician peer review in many cases. With client approval and per jurisdictional requirements our team will contact the treating physician(s) to:
- Clarify ambiguous medical treatment
- Find out if procedures, surgeries, or other therapies are still being considered
- Share information about multiple prescribers or pharmacies and duplicative or very similar medications
- Discuss high doses of opioids and other addictive drugs
- Ask the provider to consider tapering programs and alternative pain management options
- Determine the current frequency of urine drug tests if applicable
- Confirm the discontinuance of medications
- Request a switch from brand drugs to generics
- Obtain the last treatment date
- Confirm the current injury-related drug regimen
This an area where Tower excels. We obtain the doctor’s statement in language that is clear, concise and in a format acceptable to CMS. Notably, 83% of the MSAs we submitted in 2020 were approved with no Development Letters. Next time there’s an opportunity to use our Physician Follow-up service, do it. There’s nothing to lose and a lot to save.
To see this and some of our other case studies, go to Successes, and if you need help with settling the claim right now, get in touch with Hany Abdelsayed, firstname.lastname@example.org, (916) 878-8062.
Posted on June 11, 2021 by Daniel Anders
The Centers for Medicare and Medicaid Services (CMS) has issued guidance for the implementation of the PAID Act. The agency also announced criteria for an additional option for the termination of Ongoing Responsibility for Medicals (ORM) in the Section 111 reporting process.
PAID Act Implementation
On June 8, 2021, CMS issued a Technical Alert on the implementation of the PAID Act. The PAID Act (See Paid Act Becomes Law) will provide Responsible Reporting Entities (RREs), namely liability insurance (including self-insurance), no-fault insurance and workers compensation plans and insurers, Medicare Part C and D enrollment information for claimants identified as Medicare beneficiaries. Starting December 11, 2021, the following information will be provided in the NGHP Section 111 Query Response File where CMS responds to a query about a claimant’s status as a Medicare beneficiary:
- Contract number
- Contract name
- Plan benefit package number
- Plan address
- Effective dates for the previous 3 years (up to 12 instances each for Part C and for Part D)
CMS also released an updated NGHP User Guide, Version 6.4, which provides the technical information for the query response file layout additions that will be required to receive this information through the query process.
Our Section 111 reporting team is reviewing the technical changes and will provide guidance to our reporting clients regarding system updates that need to be made before December 11, 2021, to enable receipt of the new field data. We will also participate in testing, which CMS says will be available by this coming September 13. Finally, we will attend CMS’s June 23 webinar on the PAID Act implementation and provide a summary of any relevant information.
Additional Option for ORM Termination
Besides the PAID Act, the updated Section 111 User Guide provides a new option for ORM termination. Per Section 6.3.2 of the Section 111 User Guide (Policy Guidance), once ORM is accepted on a claim it can only be terminated if certain criteria are met:
- Where there is no practical likelihood of associated future medical treatment, an RRE may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
- Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;
- Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.
CMS has now provided additional criteria which allow ORM termination:
Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:
- No claims were paid with any diagnoses codes related to alleged ingestion, implantation, or exposure; and
- No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and
- Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and
- The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.
Note: If, at any time, any of the parameters set forth above should no longer be applicable, the insurer must then update the ORM record to reflect that they, once again, have ongoing responsibility for medicals (i.e., update the termination date to all zeroes). Should the case once again fall under these parameters (for example, if five years elapse from the last relevant date of service), then ORM for that case may once again be terminated in accordance with the criteria above.
This policy gives RREs the ability to terminate ORM or not report ORM in the first place on minor medical claims. We recommend a review of all outstanding claims with an open ORM that could fit these criteria to decide whether an ORM termination date should be entered.
For example, a Medicare beneficiary claimant has a traumatic injury on February 1, 2014. Acceptance of ORM was reported through the Section 111 reporting process. The last medical paid was for a date of service of March 1, 2016, where the total paid on the claim was $10,000. On March 1, 2021, five years have passed and ORM may be terminated. Note, if the claim is later settled, the settlement amount would still need to be reported as Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process.
In addition to claims where ORM is currently open, this policy would apply to claims where potential ORM acceptance reporting was triggered because a claimant was identified as a Medicare beneficiary.
For example, the last medical paid in a traumatic injury was for a date of service of March 1, 2016, where the total paid on the claim was $10,000. Medical remains open on the claim per state law. The claimant became a Medicare beneficiary on June 1, 2021. Per this policy, ORM acceptance would not need to be reported because all criteria have been met. Note, like in the example above, if the claim were to settle, the settlement amount would need to be reported as Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process.
If you have questions about the PAID Act or the changes to ORM reporting, please let me know. Contact me at email@example.com or 888.331.4941
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Posted on May 27, 2021 by Tower MSA Partners
Trying to bring more of your legacy claims to settlement?
This could be the most valuable webinar you’ll ever attend!
Do you have aging claims that continue to draw down on indemnity and medical reserves? Perhaps there is no ongoing medical, but the injured worker was unwilling to settle. Or maybe a claimant is willing to settle, but a prior MSA placed settlement out of reach.
These legacy claims can be settled with a program that aggressively addresses Medicare Set-Aside (MSA) cost drivers and mobilizes a settlement team that paves the way to claim closure–without increasing your adjuster’s workload.
You are invited to join Hany Abdelsayed, Tower’s expert in legacy claims settlement initiatives, for a fast-paced webinar on Thursday, June 24 at 2 p.m. Eastern. You’ll learn about:
- Recognizing legacy claims both obvious and hidden
- Identifying MSA cost drivers, which impede settlement
- Clinical interventions that contain MSA costs
- Settlement partners who clear the path to settlement/claim closure
A Q&A session will follow the presentation. Please click the link below and register today!
Posted on May 25, 2021 by Daniel Anders
On Wednesday, June 23 at 1 p.m. ET the Centers for Medicare and Medicaid Services (CMS) will be hosting a webinar on the implementation of the Provide Accurate Information Directly (PAID) Act. Per the notice:
CMS will be hosting a webinar to discuss upcoming impacts to Section 111 Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) related to the PAID Act, which was signed into law on December 11, 2020. The intention of the PAID Act is to help NGHP Responsible Reporting Entities better coordinate benefits by providing additional beneficiary Part C and Part D enrollment information. This webinar will cover what the PAID Act is, details of the NGHP Section 111 Query Response File changes, information on the scheduled testing period and implementation timeframes. The webinar will also be followed by a live question and answer session with staff from CMS and the Benefits Coordination & Recovery Center.
Further background on the PAID Act can be found in Tower’s article: PAID Act Becomes Law
We encourage anyone involved in the Section 111 reporting process to attend the webinar. Tower will provide a post-webinar summary.
If you have any questions, please contact Tower’s Chief Compliance Officer, Dan Anders, at firstname.lastname@example.org or 888.331.4941.
Posted on May 20, 2021 by Tower MSA Partners
Tower believes strongly that the true business value of a Medicare Set Aside (MSA) is in its ability to facilitate the settlement of a workers’ compensation claim. Dan Anders shared insight on this topic in this week’s WorkCompWire’s Leaders Speak column, Getting Real Value out of Your MSA.
Some WC payers see an MSA as a necessary evil when it comes to trying to settle a claim with an injured worker who is at or near Medicare age. They have an MSA company tally the future medical and pharmacy costs and either accept the allocated cost as is or freeze in sticker shock and put off any thought of settlement. They might even settle part of the claim and choose to keep medicals open and remain at the mercy of medical inflation.
But there’s another, better option: use the MSA as a settlement tool. Dan’s article lays out the facts and shows you how to use an “optimized MSA” and settlement partners to settle a workers’ comp claim.
What is an Optimized Medicare Set Aside?
The word optimize means “to make as effective, perfect, or useful as possible.” For Tower, a useful MSA helps settle a claim. An effective MSA achieves the perfect balance of care, compliance and cost.
Tower reviews the claimant’s medical records carefully for cost drivers – things like brand name drugs when generics are available or discontinued medications and inappropriate or open-ended treatment. Once these are identified, we recommend clinical interventions. With our clients’ approval, we implement these interventions. Our Physician Follow-up service, offered at no charge when preparing an MSA, clarifies medical treatment and drug regimens with the treating physician(s), escalates the case to Physician Peer Review when needed, and obtains physician statements that document current, appropriate treatment in language CMS can use to approve the MSA.
We make MSAs as useful as possible, and we know how to build a great team of settlement partners. Don’t settle for less.
If you have questions about settling with a CMS-approved MSA – or without one – or want to talk about any Medicare Secondary Payer compliance issue, contact Dan Anders at Daniel.email@example.com
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