MSP Compliance Blog

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

Dan Anders in WorkCompWire: Getting Real Value Out of Your Medicare Set Aside

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.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?

Paying Tribute to Dedicated Professionals During Nurses’ Month

Posted on May 14, 2021 by Tower MSA Partners

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.”

 

Dan Anders in WorkCompWire: Avoiding Section 111 Reporting Penalties

Posted on May 11, 2021 by Tower MSA Partners

With a name like “Mandatory Insurer Reporting” and potential reporting penalties of up to $1,000 per day per injured worker, one would think payers would take Section 111 reporting penalties pretty seriously. But since these penalties have never been enforced, avoidance of penalties has not been a top concern.

It looks like Section 111 penalties could be coming soon, though. The Centers for Medicare and Medicaid Services (CMS) positioned itself to implement them by proposing specific regulations last year. The agency solicited comments from stakeholders last April and could publish final regulations at any time.

Tower’s Chief Compliance Officer, Dan Anders, wrote an article in this week’s WorkCompWire Leaders Speak series, Plan Now to Avoid Pending Medicare Reporting Penalties, that recaps the history of Section 111 reporting and outlines reporting errors and CMS’s proposed penalties. And, unlike many articles that just tell you what CMS says, Dan’s piece recommends ways readers can steer clear of potential errors and problems.

Speaking of steering clear, if you’re not already using Tower’s S111 Management Dashboard, ask Hany Abdelsayed to take you for a test drive. Contact Hany at hany.abdelsayed@towermsa.com or 916-878-8062.

For more details on Section 111 reporting and Civil Money Penalties, check out Dan’s prior posts:

You can always contact Dan with any questions or concerns about this or any other compliance or MSA issues. He can be reached at daniel.anders@towermsa.com.

Updated CMS Policy Changes Medicare Set-Aside Seed Calculation

Posted on April 29, 2021 by Tower MSA Partners

An updated CMS policy change to the Workers’ Compensation MSA Reference Guide changes the Medicare Set-Aside seed calculation

On April 19, 2021, the Centers for Medicare and Medicaid Services (CMS) released an updated Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide, Version 3.3, which made a slight but notable addition to how the Medicare Set-Aside seed calculation seed amount is determined.  Specifically, CMS now requires the MSA seed amount to include the cost of the first surgery/procedure for each body part.  Previously, CMS accepted only one surgery in the seed even when there were additional surgeries for other body parts in the MSA allocation.

When settling parties choose to fund the MSA with an annuity, there is an initial deposit called the seed amount. The seed amount, under the prior rule, included the first two years of annual payments and, when applicable, the cost of the first surgery/procedure, the first replacement DME if the cost exceeds $500 and sometimes injections.

For example, an overall Medicare Set-Aside amount of $100,000 might breakdown to a $25,000 seed amount (with one surgery) with the remaining $75,000 placed in an annuity.

Under the new rule, requiring the Medicare Set-Aside seed calculation amount to include the first surgery for each body part does not change the overall MSA amount, but it puts more funds in the seed amount and less in the annuity. With the annuity less, the cost to the employer or carrier to fund the MSA will be more. In other words, taking the above example, where previously the seed amount was $25,000 (to include one surgery), the seed may now be $45,000 (to include two surgeries) with the annuity only funding $55,000.

CMS also made some other minor changes in this updated guide:

  • Updated the link to the CDC Life Expectancy table used by CMS (Section 10.3)
  • Added language confirming medication refills should be included when pricing intrathecal pumps (Section 9.4.5)
  • Noted that a Consent to Release “must be signed (by hand or electronically) with the full name of either the claimant, matching the claimant’s legal name, or by the claimant’s authorized representative, if documentation establishing the relationship is also provided. It must be a full signature, not initials.” (Section 10.2)
  • Clarified section regarding access to cases via the WCMSA Portal for Professional Administrators that were not the original submitters (Sections 16.2 and 19.4)
  • Updated the Major Medical Centers table for a Missouri entry (Appendix 7)
  • Added disclaimer to Appendix 4 stating that CMS does not endorse any of the listed products it uses for reference in calculating the MSA.
  • Noted that Conduent Strataware® was added to Appendix 4 as a tool for repricing medical bills to state mandated fee schedules, as well as usual, customary and recommend rates.

If you have any questions about these updates, please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com or (888) 331-4941.

Related Prior Posts:

CMS Adds New Pricing Resource to WCMSA Reference Guide

CMS Expands MSA Amended Reviews & Modifies Consents to Release in Updated Reference Guide

Tower MSA Partners Completes SOC 2 Type II Audit

Posted on April 28, 2021 by Tower MSA Partners

In our unwavering commitment to data privacy and security, Tower MSA Partners has completed its SOC 2 Type II audit. The SOC 2 Type II audit reports on a service organization’s non-financial reporting controls and processes as they relate to the Trust Services Criteria developed by the American Institute of Certified Public Accountants (AICPA). It tests the organization’s controls related to security, availability, processing integrity, confidentiality, and privacy over an extended period of time.

From the beginning, Tower has been committed to technology driven processes to bring efficiency and measured results to our clients.  The SOC 2 Type II attestation demonstrates how our corporate governance effectively assesses and manages risks and ensures the integrity of the systems and processes delivered by Tower and its business partners to execute the same high level of protection throughout the supply chain.  I’m extremely proud of this leadership team and its accomplishments.

Conducted by KirkpatrickPrice, the audit verified the fairness of the presentation of management’s description of the service organization’s system and the suitability of the design and operating effectiveness of the controls to achieve the related control objectives included in the description throughout a specified period.

“Tower delivers trust-based services to their clients, and by communicating the results of this audit, their clients can be assured of their reliance on its controls,” said KirkpatrickPrice President Joseph Kirkpatrick.

Related Prior Posts:

Tower MSA Partners Receives SOC 2 Type I Attestation

Building a Better Tower

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Helen King Patterson
813.690.4787
helen@kingknight.com

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