CHALLENGE:
Tower submitted a $0 MSA based upon a Tower-obtained treating physician’s statement that the work-related right shoulder rotator cuff sprain had completely resolved with no need for future medical care. CMS responded with a $17,729 counter-higher to include annual orthopedic visits, multiple primary care physician visits per year, diagnostic testing, physical therapy and Norco.
SOLUTION:
A Re-review was submitted to CMS based on records obtained from the claimant’s primary care physician which documented that Norco was being prescribed for an unrelated low back condition. Further, besides reasserting the treating physician’s statement confirming the work-related right shoulder sprain as resolved, it was also highlighted to CMS that upon claimant’s release from care there were minimal reports of pain and he was released to full duty.
RESULTS: Savings of $17,729
CMS removed all treatment and medication from the MSA and approved the $0 allocation.
Upon receipt of a CMS MSA counter-higher, Tower’s reconciliation process provides for an automatic re-review request to CMS when a reasonable basis exists to dispute the determination. In this case, Tower’s Physician Follow-Up service followed by the re-review, was instrumental in the successful $0 MSA approval. Tower’s Physician Follow-Up service, as well as MSA re-reviews, are provided at no charge when initiated as part of the MSA and CMS submission process.
