Posted on November 22, 2021 by Daniel Anders
Over the past month the Centers for Medicare and Medicaid Services issued two alerts reminding Responsible Reporting Entities (RREs) to make sure data reported through the Section 111 Mandatory Insurer Reporting process is accurate and updated. This appears to be part of an ongoing effort by CMS to avoid unnecessary Medicare conditional payment recovery efforts.
In the first alert, entitled “Reporting of Incorrect No-Fault Policy Limits” CMS states:
Responsible Reporting Entities (RREs) are accountable for ensuring the information included in their Section 111 MMSEA Mandatory Insurer Reporting submissions is accurate. There may be situations where, depending upon state law or the terms of a given policy, the policy limit may vary. In these situations, the reported Policy Limit should reflect the actual amount the RRE has accepted responsibility for at the time the record is submitted or updated. Just as important, if the Section 111 record needs to be corrected to reflect a different Policy Limit, the RRE should update the record as quickly as possible to reflect the new policy limit. For example, if a policy allows for a minimum amount of MedPay coverage and will only allow a higher amount under certain circumstances, and those circumstances are not yet met at the time of reporting, the RRE should report the lower amount. Should the criteria that triggers the higher policy limit be met after that report, the RRE should update the record as soon as possible. Reporting of an incorrect Policy Limit or failing to timely update the record can put the RRE at risk of non-compliance with the Section 111 reporting requirements.
Inaccurate and/or uncorrected information can impact current Medicare claims payment actions. Inaccurate and/or uncorrected information also places the RRE at risk of recovery actions and increases the burden of proof upon the RRE should it attempt to dispute recovery efforts. Therefore, we advise the RRE to consider contacting their EDI Representative to submit an off-cycle Section 111 report with new policy limit information, rather than wait for their next Section 111 reporting cycle.
By recommending an “off-cycle” reporting of the new policy limit, CMS is trying to avoid paying medical expenses when a primary payer, in this case, the no-fault carrier, is available to pay. (CMS has a similar recommendation in the Section 111 User Guide for an immediate report of ORM termination to the EDI representative.) If the no-fault plan can pay medical costs directly to the provider, it streamlines the system and eliminates the conditional payment recovery process.
This portion of the alert’s language raises some concern, though: “failing to timely update the record can put the RRE at risk of non-compliance with the Section 111 reporting requirements.” While CMS has yet to issue final regulations regarding civil monetary penalties for non-compliance with Section 111 reporting requirements, in its proposal, timeliness and accuracy of reporting are factors in determining whether penalties will be imposed.
CMS could clarify this alert by stating that “failing to update the record by the quarterly reporting period following the policy change puts the RRE at risk of non-compliance.” Making failure to report “off-cycle” a basis for penalties adds confusion to a system based on quarterly reporting. Tower will seek clarification from CMS on this point.
The second alert from CMS, “Use the Funding Delayed Beyond TPOC Start Date Field,” states:
This is a reminder that if funding is delayed after the settlement date reported in Field 80: TPOC Date, in the Claim Input File Detail Record, RREs should provide the actual or estimated date of the funding determination in Field 82: Funding Delayed Beyond TPOC Start Date.
Some RREs are failing to indicate a Funding Delayed Beyond TPOC Start Date when funds have not yet been released. This has resulted in CMS recovery demands being sent based upon the receipt of a TPOC date and TPOC amount before the funds for the settlement have been received by the beneficiary.
As soon as CMS receives a report of a TPOC Date and corresponding TPOC Amount, CMS begins its recovery process to collect Medicare claims conditionally paid that are covered by the TPOC. The Funding Delayed Beyond TPOC Start Date is used to delay the recovery process so as not to negatively impact the beneficiary prior to receipt of the settlement proceeds.
In addition, the Funding Delayed Beyond TPOC Start Date is used to ensure an RRE is not found noncompliant with the Section 111 timeliness reporting requirements when a settlement has been made, but the final payment amount has not yet been determined or dispersed.
What is not explained here is that Field 82, per the Section 111 User Guide, is to be used in specific circumstances where the amount the claimant Medicare beneficiary is to be paid is not known at the time the settlement occurs. This happens most often in mass tort settlements. Here is an example from the user guide:
- There is a settlement involving an allegedly defective drug.
- The settlement contains or provides a process for subsequently determining who will be paid and how much. Consequently, there will be payment to or on behalf of a particular individual and/or the amount of the settlement, judgment, award, or other payment to or on behalf of that individual is not known as of the TPOC Date.
- Timeliness of MMSEA Section 111 reporting for a particular Medicare beneficiary will be based upon the date there is a determination both that payment will be made to or on behalf of that beneficiary and a determination of the amount of the settlement, judgment, award, or other payment to or on behalf of that beneficiary.
- RREs shall submit the date of the settlement in the TPOC Date field and the date when there is a determination both that payment will be made to or on behalf of that beneficiary and a determination of the amount of the settlement, judgment, award, or other payment to or on behalf of that beneficiary in the corresponding Funding Delayed Beyond TPOC Start Date Field.
While it’s important to remind people to use Field 82 when applicable, the alert causes confusion when it refers to the date settlement funds are “dispersed.” CMS seems to assume that the date inserted into Field 82 is not only the date that the settlement amount is determined but is the same date the funds are dispersed. However, these dates may be weeks or months apart.
We will seek clarification from CMS but based on CMS’s representation that this is the date it uses to initiate conditional payment recovery against the Medicare beneficiary claimant, we recommend placing the date settlement funds are dispersed in Field 82.
Recognizing that both alerts are somewhat technical, and questions are understandable, feel free to contact me at Daniel.email@example.com or 888.331.4941.
Posted on October 15, 2021 by Daniel Anders
Thanks to the Provide Accurate Information Directly (PAID) Act effective December 11, 2021, payers will have access to Medicare beneficiary enrollment status in Medicare Part C (Medicare Advantage [MA]) plans or Part D (prescription drug) plans. Enrollment information will be provided through the Section 111 query response file for the past three years.
Historically, workers’ compensation, liability, and no-fault insurance plans have had a difficult time trying to determine a Medicare beneficiary’s enrollment status in such plans as the current query response file only provides a yes or now as to whether the individual is enrolled in Medicare. However, as close to 40% of Medicare beneficiaries are enrolled in a Part C plan and over 70% are enrolled in a Part D plan, the potential for these plans to seek reimbursement from both payer and/or claimant is significant.
Currently, payers must ask the claimant to voluntarily provide Part C and D plan information which sometimes is never provided or is provided, but incomplete or inaccurate. Notably, Medicare beneficiaries can change plans every year, meaning in some cases many plans may have reimbursement rights over the course of a claim.
Of course, Medicare already shares Section 111 reporting data with the Part C and D plans, thus giving them the ability to seek reimbursement against a payer who may have no idea the claimant is enrolled in such a plan until they receive a demand for payment.
Great, But Now What?
Tower’s September 15 “How-to Guide for PAID Act Implementation” webinar explained how the PAID Act affects payers, the differences in recovery processes, and the new reports Tower is creating to make life easier for its clients. If you missed the webinar, contact me at Daniel.Anders@towermsa.com to request the link because there’s a lot of information.
The Section 111 query response data received from the Benefits Coordination & Recovery Center (BCRC) is changing in a big way. There are 244 new data fields. Parts A, B, C, and D will have the most recent effective dates and termination dates. Part C and D will have most recent and previous plan(s) data, up to three years of data. This will include not only the plan name, but also contract number, enrollment date, termination date, benefit package number and plan address.
Payers can receive and store this data themselves or, for Tower reporting clients, we will store it for our clients who can then obtain the data via Tower’s Section 111 portal. In other words, it is the payer’s choice whether to receive this information.
Tower will also create PAID Act-specific reports around the new data, accessible through our S111 Management dashboard. These will be:
- Most Recent Medicare Effective and Termination Parts A, B, C, and D
- All Part C data
- All Part D data
Now, the Centers for Medicare and Medicaid Services will only provide the past three years of data, but Tower will store data beyond three years for use by our clients on claims which remain outstanding past that timeframe.
Based on the MSP statute and regulations and court decisions the Part C and D plans have a right of recovery against the primary plan and all those who receive payment from that primary plan, such as the claimant and the claimant’s attorney. In some cases, a claim for reimbursement will be issued by the Part C or D plan without initiating an inquiry. Payers should use the contact information from the Section 111 data to initiate a query with the plan(s) to determine whether they have a reimbursement claim.
There are several differences among CMS recovery through Part A and B (Original Medicare) and Parts C and D recovery.
- Part C and D plans cannot access the Medicare Secondary Payer Recovery Portal (MSPRP)
- Debt collection is not split into two recovery contractors (Commercial Repayment Center (CRC) and BCRC), however, these plans might contract out their recovery efforts.
- The C and D plans also cannot refer debts to the U.S. Treasury Department; they must file suit instead.
- In our experience, Part D and C plans have significantly less unrelated charges on their claims for reimbursement compared to CRC and BCRC.
- Appeal rights are only held by the claimant unlike with Original Medicare conditional payment demands where an appeal right is also held by the payer.
Considering the above, on balance, while identifying the plan and obtaining the reimbursement claim may be a bit more difficult, Part C and D claims for reimbursement tend to be easier to resolve compared to demands from CMS’s recovery contractors.
Guidance for Addressing Part C and D Reimbursement
The following is recommended to properly resolve Part C and D reimbursement claims at time of settlement:
- Identify if the claimant is a Medicare beneficiary and enrolled in a Part C or D Plan
- Identify If the claimant was ever enrolled in traditional Medicare; if so investigate conditional payments with CRC and BCRC
- Investigate with Part C or D plan whether it is seeking reimbursement and obtain a letter itemizing reimbursement claims.
- Negotiate with Part C or D plan to remove charges unrelated to work injury or where there is a reasonable basis to dispute. These plans largely use the same dispute and appeal criteria as CRC/BCRC
- Contact plan at time of settlement to confirm final amount owed
- Resolve case with clear understanding of how plan will be reimbursed
Keep in mind that the PAID Act in no way changes Part C and D reimbursement rights nor puts any additional obligations on these plans that did not already exist prior to its passage. Nonetheless, access to plan information by payers will undoubtedly lead to a greater emphasis on contact with the plan prior to settlement. Payers should make use of this data to query the plan and identify and resolve reimbursement claims at the time of settlement.
Whether you’re ready to implement the PAID Act or not, Tower is. In fact, we’re in front of it, building out our systems, creating reports to add to our year-old S111 Management Dashboard. We’ve been watching pending legislation and posting on it all along, thinking about how it could affect you and planning for the future.
As always, if you have questions about the PAID Act or anything else MSP or MSA related, please contact me at Daniel.Anders@towermsa.com or 847-946-2880.
There’s no better time to let Tower manage your Section 111 reporting. Contact Hany Abdelsayed for the details. Hany Abdelsayed, firstname.lastname@example.org, (916) 878-8062.
Posted on October 12, 2021 by Tower MSA Partners
Carisk® Partners, a specialty risk transfer and care coordination company, Tower MSA Partners, a settlement-focused MSP compliance company, and Ametros, a post-settlement medical administration company, are launching a novel, patient-centered case closure and settlement solution. The integrated program provides continuity in care and accurate medical cost projections while improving the settlement process for injured patients and workers’ compensation payers.
“We’re excited to partner with industry leaders Tower and Ametros on this innovative program that extends the trusted relationship built with the patient in our Pathways™ 2 Recovery program,” says Carisk CEO Joseph Berardo, Jr. “This bundled program benefits all parties by ensuring an accurate, fair and acceptable settlement and post-settlement experience for the patients we are entrusted to serve.”
As the patient approaches achievement of their care plan outcomes and goals, the Case Closure and Settlement Program introduces patient settlement resources delivered by Tower and Ametros into the Carisk Pathways™ 2 Recovery (P2R) process.
“Tower identifies all the treatment and legal barriers to settlement,” said Tower CEO Rita Wilson. “With the payer’s authorization, we proactively apply interventions to resolve pharmaceutical, medical, legal, and jurisdictional issues before we prepare a Medicare Set-Aside. This yields appropriate future care for workers’ comp patients, complies with the Centers for Medicare and Medicaid’s review policies, and facilitates closure. We are thrilled to overlay our settlement-focused workflow with Carisk and Ametros to create win-win outcomes for both payers and patients.”
Ametros advocates for Carisk patients during and after the settlement process, educating them about the multiple benefits available through professional administration of their MSA.
“Our mission is to help the injured person live a better life after they accept a settlement with an MSA. In addition to paying bills from their MSA, providing discounts on their treatments, and completing required CMS reporting, we have a Member Care Team to help them navigate the health care system after settlement every step along the way,” said Ametros CEO Porter Leslie.
This comprehensive solution extends patient advocacy for workers’ compensation patients whose cases Carisk manages during and after their claims settlements by ensuring that their future medical expenses are accurately covered and that the patients receive on-going support post-settlement. Working together, our Case Closure and Settlement Program accelerates claims closure, reducing payers’ claims portfolios, adjuster burdens, along with their medical, pharmacy, and indemnity costs.
To learn more, please contact Kristine Dudley, Tower’s Chief Operating Officer, at (888) 331-4941 or Kristine.email@example.com.
About Carisk Partners and Pathways™ 2 Recovery
Carisk is a specialty risk transfer, care coordination company serving insurers, government entities, self-insured plan sponsors, and other managed care organizations. With a foundation in behavioral health, Carisk’s end-to-end combined solutions include risk-transfer and care coordination of delayed recovery, complex catastrophic cases and MBHO services. Carisk’s Pathways™ 2 Recovery program guarantees to improve outcomes and reduce overall cost of quality care by applying best practices and a patient-centered approach to manage complex challenges for the Group Health, Casualty and Auto markets. Carisk is the first and only Managed Behavioral Healthcare Organization with dual accreditations from both the National Committee for Quality Assurance (NCQA) and the Accreditation Association for Ambulatory Healthcare, Inc. (AAAHC). Visit www.cariskpartners.com to learn more.
About Tower MSA Partners
Based in Delray Beach, Florida, Tower MSA Partners provides MSP compliance and MSA services nationally. The company leverages the latest technology to seamlessly integrate, automate, measure, and manage every process from Section 111 reporting, conditional payment resolution and MSA optimization through claim closure and settlement. Tower is a nationally certified Women’s Business Enterprise (WBENC) and has received its SOC2 Type II attestation. For more information, visit https://towermsa.com/ and https://towermsa.com/blog/.
Ametros is the industry leader in post-settlement medical administration and a trusted partner for thousands of members receiving funds from workers’ compensation and liability settlements. Founded in 2010, Ametros provides post-settlement medical management services with significant medical and pharmacy discounts along with automated payment technology and Medicare reporting tools. Headquartered just north of Boston in Wilmington, Massachusetts, Ametros may be reached at 877.275.7415 or via www.ametros.com
Posted on September 21, 2021 by Rita Wilson
We’re celebrating the Tower MSA Partners 10-year anniversary this year! To commemorate this landmark year for our business, we’ve compiled 10 distinguishing achievements over the decade that we’re proud of and that we think differentiate us from others in our field.
- Our single focus. We don’t try to be all things to all people, we focus on doing one thing extremely well. Everything we do is geared toward smooth settlements with 100% compliance with Medicare, cost-effective Medicare Set-Asides (MSAs) and partnering with clients on outcomes. Focusing our business model on Medicare Secondary (MSP) compliance and MSAs enabled Tower to develop technology specifically for this industry, hone our expertise, and become the industry’s “go-to” experts in these areas.
- We are “Measurably Better.” Our tag line “Measurably Better” is not just a clever use of words, it’s the backbone of all that we do. We run our business on metrics, tracking and measuring everything that matters in MSP compliance and MSAs. Metrics drive Tower’s internal efficiency improvements and technology enhancements. It’s how we help our clients improve their MSP compliance and MSA programs and how we prove we—and our clients’ programs–are measurably better.
- Our commitment to continuous improvement. We’ve aggregated 5 years of CMS response data to identify CMS performance metrics that matter to our clients and we track these monthly. And we continue to monitor every response CMS has to every one of our MSA submissions. When we think CMS is wrong, we challenge by proactively pushing the envelope to get the best possible results for our clients. Otherwise, we use the response data to reverse engineer internal processes to improve our MSA work product.
- Everything we do is technology driven. We built our own technology from the beginning specifically to address this industry and our clients’ needs. Our technology is based on the best practices of MSP compliance and MSA preparation. There’s no patchwork of disparate systems or data in silos that needs to be extracted, just a seamless, integrated system that drives all compliance and MSA processes. Tower’s Section 111 Management Dashboard gives clients full visibility into their claims from a global level all the way down into the details of an individual claim. Technology Drives Better Medicare Secondary Payer Compliance.
- Our commitment to cybersecurity. With a clear understanding of the importance of our systems, software, and data to Tower’s business functions and a keen awareness of the reality of cyberthreats in today’s digital environment, Tower has taken major steps to develop its enterprise-wide security infrastructure to guard against, detect and mitigate cyberattacks. This includes partnering with a data security firm that monitors data traffic 24/7, responds to threats in real time, provides direction to keep client data secure, and gives Tower unlimited access to incident response resources if attacks occur. monitoring data traffic 24/7, responding to threats in real time and Building a Better Tower – Cybersecurity.
- We’ve earned external third-party validation. Tower MSA Partners completed its SOC 2 Type II audit, providing external third-party validation that a service organization’s information security practices meet industry standards stipulated by the AICPA. Tower MSA Partners Completes SOC 2 Type II Audit.
- We are independent and women owned. We are wholly owned by our founders, CEO, Rita Wilson and COO, Kristine Dudley, Tower is a certified Women’s Business Enterprise (WBENC). Celebrating Tower’s History as a Women-Owned Business.
- Our stellar team. You can meet our outstanding leadership team, the top experts in the business. The passion and dedication of our certified MSA specialists, nurses, Quality Assurance team, and compliance staff are incredible. Their efforts enable Tower to manage by our metrics and drive results. Many have been with us since the beginning and became managers as they gained knowledge and skills. We are a cohesive team at all levels. But for our real secret sauce, learn more about how Tower Nurses Make a Difference.
- We get results. Our systematic, aggressive approach to identifying and reducing unnecessary cost-drivers on MSAs saves clients hundreds of thousands of dollars on MSAs. Our certified specialists know what to look for and our technology, metrics, and processes give them all the tools they need to find every cent of savings. Because we record CMS response to every MSA, we can confidently produce MSAs that balance care, cost, and compliance. Check out our case histories, request others or ask for a free second opinion on an MSA.
- Our clients love us. Hers’s an excerpt from one: “Second to None”….When I hear this idiom, I immediately think of Tower MSA Partners… While there are many MSA vendors, only one company, Tower MSA Partners, is “Second to None.” Tower serves their partners by guiding and directing from start to finish. They have advanced technology and certified specialists to ensure no stone is unturned. Regardless of the complexity or how fast you need help, Tower leads and delivers results that are always accurate and timely, serving you like family. Bryan Conner, Manager, Workers’ Compensation, American Airlines. See our Testimonial page to read more from Bryan and our other clients.
We are honored to serve clients like American Airlines, Acuity Insurance, Aramark, BETA Healthcare Group, CPC Logistics, Montana State Fund, Tyson Foods, and others, some who prefer not to have their names published. From the beginning, Tower sought partnership relationships with clients; we put “partners” in our name.
On our 10th Anniversary, I want to thank our client partners who have trusted us with their MSP and MSA needs, our employees who are just stellar, and our executive leadership team who are the best of the best. We look forward to continuing to serve our existing clients, help new ones achieve their goals, and continue our close partnerships.
Posted on September 1, 2021 by Tower MSA Partners
To submit or not submit a Medicare Set-Aside for approval from the Centers for Medicare and Medicaid Services (CMS) has been a hot-button issue for several years. While some follow a global non-submit strategy others opt to follow CMS’s guidance, where possible, considering a non-submit MSA only in specific situations. Whether a Non-Submit MSA is utilized for settlement depends on several factors and risk tolerances, and Tower MSA Partners stands ready to analyze your claim and help you decide.
A Non-Submit MSA, sometimes called an Evidence-Based MSA, may be a reasonable alternative when the settlement does not meet CMS’s Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) review thresholds. It may seem obvious to use a Non-Submit MSA when the MSA will not be submitted to CMS, but as the methodology in drafting the Non-Submit MSA varies from CMS policy (as detailed below) some prefer to stick to CMS policy for drafting the MSA, even when not submitted.
Besides utilizing a Non-Submit MSA when CMS MSA review thresholds are not met, as the review process is voluntary, settling parties may choose a Non-Submit MSA even when the review thresholds are met. This carries with it inherent risks in that CMS takes the position that if the funds set-aside prove insufficient “Medicare will refuse to pay for services related to the WC injury (and otherwise reimbursable by Medicare) until such expenses have exhausted the entire dollar amount of the entire WC settlement.”
A Non-Submit MSA report may have a lower allocation amount than a CMS-approved MSA because of the following features:
- Full Use of Evidence-Based Medicine – Use of evidence-based medicine, i.e., Official Disability Guidelines (ODG) or state treatment guidelines to determine reasonable care to allocate in MSA.
- CMS inconsistently uses evidence-based medicine in its MSA review process. Using ODG and state treatment guidelines may result, for example, in a lower frequency of diagnostic testing or physical therapy visits compared to a CMS-approved MSA.
- Examining Physician Opinions Considered – Both treating and examining physician recommendations are considered in drafting the Non-Submit MSA.
- CMS gives little consideration to examining physician opinions in its approval process. Depending on the case, the examining physician may be in a better position to provide appropriate recommendations for current and future medical care because of their expertise and the timing of their opinion. For example, a recent IME opinion on the necessity of surgery may be followed as opposed to a treating physician recommendation from a year ago.
- State Statutes and Regulations Followed – Fully follow state statutory, regulatory, and other legal bases for including or excluding care from the MSA.
- While CMS approval requires an “Alternative Treatment Plan” when medical care is denied through a statutory utilization review (UR) process, a Non-Submit MSA will exclude care solely based on the UR determination. For example, a prescription medication will not be allocated in the MSA when a UR determination supports denial.
- Claimant Statements and Agreements Considered – Consideration of claimant statements and settling party agreements concerning future medical care.
- CMS will not usually exclude the cost of care from an MSA for a procedure or device, such as a spinal cord stimulator, based on a claimant’s statement that they will not pursue that care. Yet that statement or an agreement among the parties that certain medical care is disputed and not included in the settlement, is sufficient for a Non-Submit MSA. For example, evidence of the claimant repeatedly refusing surgery will usually result in its exclusion from the MSA.
- Professional Administration Recommended: Except for minor MSA allocations, Tower strongly recommends having a professional administrator manage the Non-Submit MSA funds. If CMS ever questions the use of these funds, proper administration will confirm they were spent properly, enabling a seamless transition to Medicare for payment if the funds run out. And, Tower proudly partners with Ametros for professional administration of all MSAs: Non-Submit MSAs and those that are CMS-approved.
Depending on the facts of the case, a Non-Submit MSA can have a significantly lower allocation than a CMS-approved MSA and still reasonably consider Medicare’s interests. Nonetheless, using a Non-Submit MSA poses risks to the settling parties that should be fully considered and accepted prior to settlement.
Tower offers free consultations on Non-Submit MSAs. If you have any questions about these or other areas of Medicare Secondary Payer compliance, please contact Dan Anders, Chief Compliance Officer, at firstname.lastname@example.org or 888.331.4941.
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