MSP Compliance Blog

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

Tower MSA Partners to Sponsor Workers’ Compensation Institute (WCI) – TV

Posted on August 1, 2017 by Tower MSA Partners

Tower MSA Partners is sponsoring WCI-TV, the televised coverage of Workers’ Compensation Institute’s Workers’ Compensation Education Conference, and is dedicating its TV segments to examining opioids.

“Tower is pleased to partner with WCI to sponsor WCI-TV for the 3rd consecutive year and participate in the interview process throughout the conference. With opioid use in the forefront of issues facing workers’ compensation payers, we will explore prescribing habits, addiction and interventions from different disciplines within the system,” said Rita Wilson, CEO of Tower MSA Partners.

Some of the perspectives and industry leaders featured in Tower’s interviews are:

  • Claims ManagementCarrie Struzynski, RN, LHRM, CHRM, MSN, PhDc, Quarterback/Senior Manager, Risk Management, Safety & Insurance, Randstad North America, Inc.
  • MSP ComplianceDan Anders, Chief Compliance Officer, Tower MSA Partners
  • Peer ReviewMark Pew, Senior Vice President, PRIUM
  • PhysicianMel Pohl, MD, FASAM, Chief Medical Officer, Las Vegas Recovery Center
  • Pharmacy Benefit ManagementPhil Walls, RPh, Chief Clinical & Compliance Officer, myMatrixx
  • Public PolicyMark Walls, Safety National’s Vice President of Communications, and Kimberly George, Senior Healthcare Advisor, Sedgwick Claims Management Services

From its studios near the exhibit hall, WCI-TV’s programming will be aired throughout the conference area, in conference hotels’ guest rooms, on shuttles, WCI’s website, e-blasts, and on You Tube. It is produced by CNTV, a Winter Park, Florida-based company that delivers a news approach to the convention television business.

The 2017 WCI WCEC will be held August 6-9 at the Orlando World Center Marriott.

The full article may be found here.

WorkersCompensation.com: Tower MSA Partners’ Rita Wilson Predicts CMS Re-Review Changes Will Help Payers

Posted on January 27, 2017 by Daniel Anders

Tower MSA Partners CEO, Rita Wilson, was recently interviewed by WorkersCompensation.com following her participation in a January 24, 2017 “State of MSP” webinar presented by the National Alliance of Medicare Set-Aside Professionals (NAMSAP).

Workerscompensation.com asked Rita to comment on CMS’s December 21, 2016 announcement regarding its plans to update its WCMSA re-review process in 2017. This includes expansion of the process to previously approved MSAs where there has been a substantial change in the claimant’s medical condition and the case has not settled (For details see Tower MSA blog on the announcement: CMS Announces Plans for 2017 Expansion of MSA Re-Review Process & New Policy Regarding URs in MSAs)

Rita’s comments to WorkersCompensation.com follow:

“CMS will need to establish the parameters for re-review and define ‘substantial changes.’ We expect costly procedures such as surgeries and spinal cord stimulators to be included,” Wilson said. “A WCMSA involving patients who have weaned off expensive polypharmacy regimens could also qualify.”

“Tower’s workflow and decision-tree software application identifies recommended, not-yet-performed procedures and intervenes to address inappropriate treatment prior to submitting an MSA,” Wilson said, “But this could be a game-changer for payers with CMS-approved MSAs that they were unable to settle.”

The full article may be found here.

Christmas Miracles Can Happen in Workers’ Compensation

Posted on December 23, 2016 by Rita Wilson

For those of us who deal with MSAs, it’s all too common to see claims at settlement time that started out as basic and simple, then spiraled downward as a result of bad prescribing habits, increased drug use and opioid addiction.  We hope for a different ending, but can  miracles really happen?

Background

In late 2015, Tower completed a pharmacy project for a small employer in California.  In the course of the project, drug triggers were identified, physicians were contacted and claimants were challenged to settle or make changes in treatment.  As you might imagine, many of the physicians fought the request for change.  But through perseverance, and working in tandem with the client, we pushed forward.

The Story as Shared by our Client

Dear Hany,

A few weeks ago, I was looking over the  case for one of the California claimants and wanted to share the amazing results we have achieved with this gentleman.

This case involved a 26 year old man at time of injury. He sustained a minor back injury but was taking Hydrocodone, Testosterone, Celecoxib, Lyrica, Nortriptyline, Methocarbamol, and FENTANYL.  With the recommendations and assistance from the Tower MSA Partners team, as well as support from his wife, we were able to get him into a new treating physician who agreed with our goal. He was weaned off of the Fentanyl, Methocarbamol, testosterone, hydrocodone, and Celecoxib. He has even started an exercise program.  He is now both proud and happy to report how well he is doing.

The injured worker is now 51 years old and he sadly notes that he missed out on 25 years of his life and his children’s lives because he was so “drugged”.   On a positive note, however, his new treating physician has been wonderful to work with and we see only good things for this claimant.

On the financial side we have now realized a reduction in the monthly Rx spend from $1,200 per month down to $600.  The injured worker is now only taking Nortriptyline, Lyrica and Celebrex and we expect to reduce reserves next year and approach him for a settlement in June, 2018.  None of this would have been possible if not for the Rx project and your team’s expertise, guidance and follow up assistance.

While we have had great success with many of the claims that we partnered on, this particular claim was really about improving his quality of life.  So please share my THANK YOU and gratitude with your team. Let them know that what they do can save a life and that is priceless.

It’s True….Miracles Can Happen in Workers’ Compensation

What a wonderful way to end the day and begin our holiday celebrations!

From all of us at Tower MSA Partners, our best wishes for a wonderful holiday, and a safe and prosperous 2017!

CMS Hits ‘Reset’ Button With Workers’ Compensation Review Contractor Procedures and Request for Approval of Zero-Dollar Medicare Set-Aside Amounts

Posted on November 2, 2016 by Rita Wilson

In an announcement distributed on November 1, 2016, CMS acknowledged the receipt of many inquiries from the MSP industry regarding procedural changes in the way CMS’s  Workers’ Compensation Review Contractor (WCRC) reviews proposed zero-dollar Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) amounts.  CMS further acknowledged that as a result of these inquiries, it has determined that changes had transpired without prior notification, and that effective immediately, the WCRC will utilize (the) procedures that were previously in effect, further noting that CMS continually evaluates all policy and procedures related to WCMSA reviews and will publish any pending changes when or before they go into effect.

Background

Prior to October, 2016, the Workers’ Compensation Review Contractor’s procedure with Zero Dollar WCMSAs in cases where evidence of a complete denial of the claim was handled as follows:

  1. The carrier’s complete denial would be evidenced by
    • a claim payment history documenting no payments for medical treatment and indemnity and
    • a letter from the adjuster or defense attorney confirming such full denial.
  2. The MSA must be submitted to CMS for approval PRIOR to obtaining a court-approved settlement.

When these conditions were met, the settlement would be recognized as a strict compromise and CMS would issue a determination letter staying no MSA is needed.

While CMS never published this procedure as an official policy in the WCMSA Reference Guide, the policy was exercised regularly and consistently.   As such, Tower, as well as many other MSP companies, incorporated this “policy” into its standard CMS submission procedure for Zero WCMSAs for denied claims.

The October ‘Surprise’

Beginning in October, 2016, with no notice, CMS responses for denied claims took a complete 180 degree turn in terms of the WCRC’s review process.  No longer was the carrier’s evidence of complete denial of the claim sufficient to obtain CMS’s approval of a Zero WCMSA.

When questioned regarding its rationale for this drastic change, CMS noted only that there was a ‘NEW‘ procedure being followed by the WCRC, and in order to obtain approval of a Zero WCMSA one of the following would be required:

  1. A court ruling regarding the compensability of the claim; or,
  2. Treatment records (i.e. a letter from the treating physician) which demonstrate/indicate that no further treatment for the alleged industrial condition(s) will be required.

Unfortunately for the industry, there was no advanced notice of the change in procedure, no documentation of the change and no explanation of CMS’s rationale for making such a drastic change.  We, along with everyone else in our industry, basically learned about this through development letters and undesirable dialogue with WCRC & CMS representatives.

Industry Reaction and CMS’s ‘Reset’

As expected, companies reacted immediately, contacting CMS to request answers, and seeking to determine how WCMSAs currently being reviewed would be handled.  Tower clients with cases pending with CMS were advised to wait to see if the case would be developed or if CMS would follow its original policies.  If developed, the case could be withdrawn.

In an effort to further clarify, NAMSAP (National Alliance of MSA Professionals) also intervened on behalf of its constituent members to confirm why the change was made, to ‘demand’ the courtesy of notice, and to offer its expertise to assist CMS in setting future policy to simplify the process rather than creating confusion and chaos.

As a result of the avalanche of questions, concerns and complaints, CMS has now taken a very positive step back, announcing that it will revert to its original, established procedure for reviewing Zero WCMSA for denied claims until such time as it can analyze, define policy, establish review procedures, communicate to the MSP industry and provide ample notice.

What’s Next?

With today’s announcement that the WCRC will revert to its original procedure for reviewing Zero WCMSAs for denied claims, the industry can return to its internal policies for setting settlement strategy with a clear understanding of the review process that will be executed by CMS’s review contractor when evaluating Zero WCMSAs.

As a reasonable next step, NAMSAP has offered to serve as a resource to CMS to provide industry experiences, to identify the perceived impact of the WCRC’s shift in policy, and to open dialogue regarding both our goals and the unintended consequences of CMS’s shift in review practices.  I trust CMS will consider this offer, and will engage in conversations that will lead to a seamless

Stay tuned….

Related:

Denied Claim Zero MSAs: Still Available, but Put Through the Wringer by CMS

CMS: Workers’ Compensation Medicare Set Aside Arrangements

FDA Mandates New Warnings for Opioid and Benzodiazepines

Posted on September 20, 2016 by Rita Wilson

Hydrocodone Rescheduled

In a statement released on September 1, 2016 (FDA Black Box Warning), the Food and Drug Administration (FDA) announced that “after an extensive review of the latest scientific evidence, it is requiring class-wide changes to drug labeling, including patient information, to help inform health care providers and patients of the serious risks associated with the combined use of certain opioid medications and a class of central nervous system (CNS) depressant drugs called benzodiazepines.”

Background

Benzodiazepine medications are most commonly prescribed to treat anxiety and mood disorders, such as depression and insomnia. The drugs also are used to treat seizures.  According to the FDA, the number of individuals who were prescribed both opioids and benzodiazepines grew by 41 percent, or 2.5 million, between 2002 and 2014.

States submitted a petition to FDA calling for the agency to add black-box warnings about the potentially fatal combination of opioid painkillers and benzodiazepines to the drugs. The officials said prescription opioids and benzodiazepines often are used together, and data show that almost one in three unintentional overdose deaths from prescription opioids also involved benzodiazepines.

What drugs are impacted?

The agency is requiring that black box warnings, the strongest available, be added to nearly 400 products (of which more than 200 are opioid painkillers) alerting doctors and patients that combining opioids and benzodiazepines can cause extreme sleepiness, slowed breathing, coma, and death.

The FDA is warning patients and their caregivers about the serious risks of taking opioids along with benzodiazepines or other central nervous system (CNS) depressant medicines, including alcohol. Serious risks include unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, coma, and death. These risks result because both opioids and benzodiazepines impact the CNS, which controls most of the functions of the brain and body.

The bigger picture

The agency said the move is one of a number of steps the FDA is taking as part of the agency’s Opioids Action Plan, which focuses on policies aimed at reversing the prescription opioid abuse epidemic, while still providing patients in pain access to effective and appropriate pain management.  For those who may not know what’s in play or want more information about the national effort, go to TurnTheTideRx.Org to access the U.S. Surgeon General’s plans to curb the epidemic.

In responding to the announcement, FDA commissioner Robert Califf noted, “It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together,” He further added, “We implore health care professionals to heed these new warnings and more carefully and thoroughly evaluate, on a patient-by-patient basis, whether the benefits of using opioids and benzodiazepines … together outweigh these serious risks.”

What does this mean to you?

In dealing with workers’ compensation claims for Class I and Class II Medicare beneficiaries, the combination of opioid pain killers and benzodiazepines is a common occurrence.  When we see it, we immediately notify the claims handler that this is a dangerous combination and certainly not intended for long term use.  For the elderly, drug combinations such as this are even more dangerous as their effects are exacerbated due to the rate at which they metabolize in an elderly person.  For those who may not be familiar, there is an excellent resource (2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults) that focuses on commonly used drugs and the risks and potential dangers when prescribed to the elderly.  According to the guide,

“Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults and should be avoided”.

One of many pieces of the opioid puzzle

As stated within the “TurnTheTideRx” campaign literature, it is truly “All hands on deck” if we hope to change the course of the opioid epidemic.  It will take patient, family members, friends, and in the case of workers’ compensation claims, claims handlers, nurse case managers, employers,  carriers and even MSP compliance providers to help change prescribing habits.  While legislative, regulatory and compliance entities can assist by setting policy, it is the physician who writes the first script.  When I see that one of the largest emergency rooms in the country (One of Nation’s Largest ERs Kicks the Opioid Habit) can function without writing opioids as first line pain management for acute pain, I am convinced that a change is possible if we can engage our physicians.

We are but one piece of this very complicated puzzle, and “Big Pharma” has deep pockets.  Through education of all stakeholders, advocacy to those in positions of power and influence, and our respective collaborative efforts to optimize claims and treatment, we can make a difference in the lives of our patients.

 

For Media Inquires, Contact:

Helen King Patterson
813.690.4787
helen@kingknight.com

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