MSP Compliance Blog

Not all Medicare Set-Asides (MSAs) are the same. There are specialty areas for unusual cases and many questions about these:

• Criteria for successful $0 MSA approvals
• Whether to include PQMEs, AMEs, IMEs in the MSA
• Use of court orders to limit medical care in the MSA
• When and how to use the MSA Amended Review process
• Correct verbiage for treating physician statements

Claims professionals and attorneys often receive conflicting or unclear information around these topics and other matters that make not only working with the MSA but the whole settlement process, tricky.

Tower is pleased to feature our Chief Compliance Officer Dan Anders, who will share tricks of the trade at a webinar on Wednesday, July 20, at 2:00 PM ET. Dan has written and submitted thousands of MSAs to CMS for almost two decades. His unique knowledge is an asset for anyone who uses an MSA in a case settlement.

A Q&A session will follow the presentation, and you can provide questions at the time you register. Please click the link below and register today!

REGISTER HERE

This success story demonstrates how an MSA Second Opinion can lead to a successful result with settlement of a WC case.

CHALLENGE:

An MSA was prepared by another MSP provider for approximately $110,000. Based on this MSA amount, the parties reached a tentative settlement. Prior to MSA submission the other MSP provider revised the MSA to $145,500 which was outside the parties settlement range. The cost drivers in the MSA were injections, surgeries and physician visits.

SOLUTION:

Tower’s MSA 2^nd opinion review found the injured worker had repeatedly declined injection therapy and one of the two surgeries had not been recommended in the past two years. Consequently, Tower recommended eliminating the surgery and injections from the MSA. Our Physician Follow Up service contacted the treating physician and obtained the physician’s written statement that injections were no longer part of the treatment plan.  The physician also agreed to reduce the number of physician visits to a single annual visit.

RESULTS:  $46,691 in Savings

In addition to eliminating a surgery that fell outside the two years of medical records required by CMS, injections were removed, and physician visit frequency was reduced yielding an MSA of $98,809. The MSA report was submitted and approved by CMS and the parties were able to move forward with settlement and claim closure.

Tower’s MSA 2^nd Opinion, offered at no charge, identifies, from another MSP provider’s report, discrepancies and inappropriate treatment which unnecessarily increases the MSA along with recommending interventions which may result in a lower CMS-approved MSA amount.

Tower’s Physician Follow Up Service, also offered at no charge, reaches out to the treating physician to confirm ongoing Rx and reduce excessive or unneeded treatments.

More Tower Success Stories can be found here!

CHALLENGE:

Tower was engaged to prepare an MSA for a 54-year-old partial quadriplegic. The lack of current medical records, the erratic behavior of the patient, the quality of the provider’s treatment coding, and unknown treatment outside of the WC Plan were challenges to preparing an accurate MSA. The preliminary MSA amount was $424,528.

SOLUTION:

In review of the treatment records, Tower’s medical experts were able to identify several instances where Medicare covered expenses could be reduced as part of Tower’s Optimized MSA process.

At Tower’s request, the client obtained current medical records. Tower’s clinical team reviewed those records and the corresponding billing codes used for all treatments. By analyzing the provider’s treatment methods against Medicare’s reimbursement requirements, Tower was able to identify items that were more accurately priced with alternative codes. One instance identified was a determination that a catheterization code (A4353) was used incorrectly. By using the correct billing code and applying other cost savings strategies to the treatment regimen, the MSA dollars were significantly reduced.

To ensure that CMS would accept the updated medical coding, Tower detailed how the original billing code was incorrectly used and then provided the correct coding.

RESULTS: $175,867 in Savings

Upon finalization of the optimized MSA, a total allocation amount of $248,661 was submitted to CMS for review and approval. CMS accepted the proposed MSA amount and responded with a Full Approval. Using Tower’s proprietary processes and technology, the client carrier was able to reduce the Medicare exposure of this settlement resulting in total savings of $175,867.

More Tower Success Stories can be found here!

Tower MSA Partners is recognized as a Top 25 women-owned business by South Florida Business Journal.

We know we’re good, but we enjoy external validation as much as the next guy – or woman. So, we were quite pleased to learn Tower MSA Partners not only made the South Florida Business Journal’s list of Women Owned Businesses, but we ranked among the Top 25.

The publication covers companies in the densely populated Miami-Dade, Broward, and Palm Beach counties. When you consider how many women-owned businesses are in this market, the honor is even more impressive. A 2016 Sun Sentinel story said nearly half of all the women-owned businesses in Florida were based in this area.

Among the metrics used to produce the list is the percentage of the company that is owned by women. For Tower, that’s 100%. CEO Rita Wilson and COO Kristine Dudley co-founded the company more than 10 years ago. You can read more about the company’s start in this article.

Tower is not only women-owned but 85% of our employees, including most of our managers and supervisors are women.

Tower is also a certified member of WBENC or the Women’s Business Enterprise National Council, a leading non-profit organization dedicated to helping women-owned businesses thrive.

If you’d like to connect with Rita or Kristie email them at rita.wilson@towermsa.com or kristine.dudley@towermsa.com.

CHALLENGE:

A Medicare Set-Aside was prepared by another MSP provider for $221,384.00.  In addition to extensive medical treatment and surgical procedures, the MSA included the medications omeprazole, ibuprofen, sertraline, and hydroxyzine.  As a settlement was not feasible with that MSA amount, it was submitted to Tower for a 2^nd Opinion MSA Review.

Tower’s 2nd Opinion MSA Review is offered at no charge.

SOLUTION:

Following Tower MSA Partners’ standard MSA workflow, the Intake team compared the reported “accepted” body parts against information in the client’s claim system and determined that sertraline, intended to treat stress and depression, should be removed as “psyche/stress” was not an accepted body part. This yielded a savings of $58,320. Additionally, Tower identified inappropriate medical treatment, including an unnecessary bladder surgery, resulting in a further $37,234 reduction. Finally, Tower obtained a rated age from K.P. Underwriting, which lowered the treatment and prescription cost over life expectancy. Tower’s MSA totaled $123,263.68.

RESULTS:  $98,120 in Savings

In addition to eliminating Rx unrelated to the injury and appropriately allocating for medical treatment, Tower recommended the following pre-CMS submission to mitigate exposure and further lower the MSA:

1. Tower drafted Body Part Letter to confirm accepted compensable conditions and specifically identified all other conditions discussed in the medical records as not “accepted” or paid for by our client.
2. Tower’s Physician Follow Up Service, offered at no charge, to reach out to the treating physician to confirm if hydroxyzine is related to the WC injury and whether omeprazole and ibuprofen can be switched from prescription to over-the-counter versions.

More Tower Success Stories can be found here!

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.