MSP Compliance Blog

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 daniel.anders@towermsa.com or 888.331.4941

 Related Prior Posts:

CMS to Host Paid Act Webinar

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!

Register now

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 daniel.anders@towermsa.com or 888.331.4941.

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.anders@towermsa.com

Related Prior Posts:

Build a Better Tower: Partnerships Speed Settlements of Workers’ Comp Claims with Medicare Set Aside

Need a Second Opinion on an MSA?

According to the American Nurses Association (ANA), May is Nurses Month, dedicated to honor, thank, and support nurses and all those in the nursing profession. They’ve designated the 2021 theme as “Nurses Make a Difference.” Plus, ANA joins the World Health Organization (WHO) and global colleagues in extending the Year of the Nurse into 2021.

Tower Nurses Make a Difference

We couldn’t agree more with the sentiment that nurses make a difference, and we join in the salute.  At Tower, nurses are an integral part of our team. RNs, who hold the Medicare Set-Aside Consultant Certification (MSCC), prepare Medicare Set-Asides (MSAs).  Tower nurses review, analyze and summarize medical records and allocate care based upon Tower’s clinical standards, evidence-based medicine, and CMS MSA guidelines.

Their scrutiny often turns up gaps in care, open-ended treatment, treatment of unrelated body parts, discontinued or inappropriate prescriptions, dangerous dosages, and opportunities to switch brand drugs to generics. Once our nurses identify ways to reduce costs without compromising an injured worker’s care, specific clinical interventions are recommended to our clients.

Separate from the nurse preparing the report, a nurse-led clinical quality assurance team the accuracy of the report and makes sure all cost-containment opportunities have been considered and are presented to our client delivery of the MSA report.  Subsequently, clinical interventions, such as Tower’s Physician Follow-up service, work to obtain a physician statement and document the current, appropriate treatment in language that CMS can use to approve the MSA as written.

The difference our nurses make can be measured in Tower’s key performance indicators, which reveal a median CMS-approved MSA of $23,205. In addition, only 40% of our CMS-approved MSAs allocate for prescription medications, and 83% of them are approved without post-submission development letters. This record of success would be impossible without the dedication of our nurses.  Thank you!

Nurses Month: Stories from the pandemic frontlines

Beyond our gratitude for the nurses on our own team, for Nurses Month, we pay tribute to nurses everywhere and in every role. Nurses have been everyone’s lifeline during the pandemic but have paid a toll for the crucial role they played. We’ve compiled some stories about the experience of nurses over the past year that we found noteworthy.

What Nurses Want You to Know About the Past Year  – In this article for AARP, Michelle Crouch gathers nurses’ reactions to the past year. Nurses say that the sheer number and pace of coronavirus fatalities was overwhelming; keeping families apart was painful; mourning patients who died was painful; fear for their own and their family’s safety was a constant backdrop. They are emotionally and physically exhausted. How can we best thank and support them?

“The best way the public can support nurses right now is to get one of those vaccines, nurses say. “Please, go and get vaccinated,” Carrell-Yoder stresses. “We don’t want to do this again. We don’t want more people to die.”

“All Hands On Deck”: The COVID-19 Pandemic Through Nurses’ Eyes – The Dose Podcast from Shanoor Seervai for the Commonwealth Fund looks at the experience of frontline nurses one year into the pandemic, with many experiencing stress, grief, and fatigue. Her guest is Mary Wakefield, a nurse and a professor who has held positions in the Obama administration and in the Biden-Harris transition team. When asked about lessons learned for going forward, Wakefield said:

” … our public health infrastructure, as many people recognize clearly now, is incredibly anemic. The largest proportion of public health workforce is comprised of nurses, and yet they’re still too few. We’ve seen an erosion in the United States public health infrastructure over the last number of years. That has got to be built back up. We need more public health nurses. Not the same, we need more.”

Nursing in the time of COVID-19: Two advanced practice nurses on the front lines of the pandemic – Johis Ortega and Juan M. González are advanced practice nurses and professors at the University of Miami’s School of Nursing and Health Studies. Ortega also serves as Associate Dean for Hemispheric and Global Initiatives at the school and González is Director of the Master’s Program in Family Nursing. In a story for the Pan American Health Organization (PAHO), they offer a portrait of their experience in treating patients in the peak of the pandemic.

It’s Always Been Tough Being A Nurse. Now It’s Worse – Tom Lynch of Workers Comp Insider tells us that nurses experience a shockingly high level of on-the-job injuries, including the highest rate of sprains and strains of all professions. And he says that:

“The COVID-19 pandemic has made things even worse. A new Washington Post – Kaiser Family Foundation Poll reveals roughly three out of ten health care workers are considering leaving the profession and more than half report being “burned out” due to the overwhelmingly horrific year they’ve just spent trying, and often failing, to save the lives of COVID inflicted patients.”