Blog Archives

Tower MSA Partners’ WCI-TV Interviews Reveal How Workers’ Compensation Companies Use Claims Data

August 19, 2022

The workers’ compensation industry has extolled the promises of data analytics and automation for years.

But how are organizations really using claims data? What strategies have worked best? And what have they learned? Several executives will share their experiences during WCI-TV interviews sponsored by Tower MSA Partners.

Guests include Dave Strange, the Yellow Corporation’s Workers’ Compensation Manager and Greg Hamlin, Senior Vice President, Resolution with Berkley Industrial Comp. Ametros CEO Porter Leslie and Alisa Hofman, Vice President of Workers’ Compensation and Medicare Practices for Arcadia will discuss the use of data during and after settlement.

In addition, Tower’s Chief Compliance Officer Dan Anders and Chief Operations Officer Kristine Dudley will share how the technology driven company uses data to streamline Medicare Secondary Payer compliance, protect clients from penalties, and optimize Medicare Set-Asides.

Tower has been the exclusive sponsor of WCI-TV since it first aired in 2015. WCI-TV airs throughout the convention center, in hotel guest rooms and shuttles, on You Tube and CI’s website. Tower’s interviews will also be shared on the company’s LinkedIn page.

The 76^th Annual WCI Conference will be held August 21-24 at the Orlando World Center Marriott. For more information, please see https://www.wci360.com/conference/.

Is a CMS-approved $0 MSA Still Possible?

July 26, 2022

Picture of a women holding the # 0 depicting a $0 Medicare Set-Aside

A common question we receive is whether a CMS-approved $0 MSA is still possible. The answer is, yes– if it meets the criteria.

There are three different ways a $0 MSA can be obtained, each with its own criteria and documentation requirements.

Denied Claim $0 MSA

This is a $0 MSA based on a completely denied workers’ comp claim when no payments have been made for medical treatment or indemnity. In certain jurisdictions, such as California, some medical payments can have been made during a statutory investigating period. Payments for non-treatment purposes such as IMEs, case management and medical records copies do not impact the ability to obtain a $0 MSA approval.

This type of $0 MSA has significant documentation requirements:

1. Claim Payment History

A claim payment history printout, even if blank, representing payments since the inception of the claim. All payments must be itemized.
Printout must be divided into categories for medical, indemnity and expenses with subtotals for each category and a grand total listed. This printout needs to include the print or run date.
If the claim payment history does not meet the above requirements, then Tower will work with you to identify alternative documentation that meets CMS requirements.

2. Draft or final settlement documents and court orders or rulings or a statement that no such documents exist (see below Financial Detail and Denial Letter). CMS recently added a requirement that there must be a proposed or agreed-to settlement. Importantly, while CMS requires a proposed settlement, it will reject the $0 MSA if the settlement is finalized, for example with court or commission approval, before CMS’s review and approval of the $0 MSA.

3. First Report of Injury or a statement that no such document exists (See below Financial Detail and Denial Letter).

4. Financial Detail and Denial Letter – At the time of submission Tower will draft a letter for the client to sign that confirms the denial of the claim and any other necessary explanations, such as why no First Report of Injury is available.

5. Medical Records: As with a regular MSA, medical records for the past two years must be provided with the submission.

6. CMS Consent to Release form executed by the claimant.

Accepted Claim $0 MSA

This is a $0 MSA based on medical documentation supporting no further need for injury-related treatment. In the WCMSA Reference Guide, CMS provides as follows:

The individual’s treating physicians conclude (in writing) that to a reasonable degree of medical certainty the individual will no longer require any Medicare-covered treatments related to the WC injury.

In practice, CMS accepts treating physician statements that say the injury-related treatment has resolved or returned to baseline (when there was a pre-existing condition) and that no further injury-related treatment will be necessary as sufficient to support the $0 MSA.

Keep in mind that CMS will not accept the physician’s statement unless it is consistent with the treatment records/notes. For example, if the physician states the injury-related has resolved, but treatment notes document ongoing pain to the relevant body part, CMS is unlikely to approve a $0 MSA. Also, if the injured worker will require a revision or replacement to a body part, e.g., a knee replacement, a $0 MSA will not be approved.

In addition to the physician statement, a claim payment history, medical treatment records and an executed Consent to Release are required.

Judicial Decision $0 MSA

CMS will accept a judicial decision after a hearing on the merits of the case as a basis for a $0 MSA. This can be on a completely denied claim where the judge upholds the denial of the claim or an accepted claim where the judge finds future medical treatment, if any, is unrelated to the work injury. The key here is the decision is “on the merits.” If it in any way looks like an agreement between the parties and the judge just stamped their approval, CMS will not accept it.

In addition to the judicial decision, a claim payment history, medical treatment records and an executed Consent to Release are required.

While there are strict documentation requirements, these $0 MSA approvals remain available for workers’ compensation cases meeting the applicable criteria. Please contact Tower MSA Partners at referrals@towermsa.com or (888) 331-4941 to refer a claim meeting these requirements or for further consultation.

Catch Tower’s Dan Anders on the popular ADJUSTED podcast

July 13, 2022

Dan Anders who was quoted in the Claims Journal

The latest episode of the popular ADJUSTED podcast features our Chief Compliance Officer Dan Anders on one of his favorite topics, Medicare Set-Asides. When are they needed? How do you mitigate their costs? What’s the deal with rated ages? Host Greg Hamlin and Guest-host Matt Yehling, Director of Claims at Midwest Employers Casualty wanted to know.

The hosts posed the all-important question of when should workers’ comp claim with a Medicare beneficiary claimant be settled: now, later or not at all? Dan guides listeners through the various elements to consider when coming to this decision. Is the Medicare beneficiary’s condition stable? Is surgery imminent? Are they still tapering off certain medications? Are there ways to lower costs without compromising care? What are the barriers to Centers for Medicare and Medicaid (CMS) approval?

While talking about ways to mitigate costs, Dan stresses the need to obtain physician statements to clarify treatment, including which medications are discontinued. CMS requires the costs for these to be included in the MSA unless changes are documented in certain ways. Tower’s Physician Follow-up service does this and has been used on nearly half of our CMS-submitted MSAs.

If you’re new to MSAs or need to know more about reducing their costs, this podcast is for you. Find it on Apple, Google, Spotify, other platforms and here: Medicare Set Asides with Dan Anders (buzzsprout.com).

Even better, you’ll learn a little more about Dan. Did you know he considered a career in politics?

Produced by Berkley Industrial Comp, ADJUSTED presents interviews with experts on a variety of topics touching workers’ comp. Other recent episodes on settlement issues were Ametros’ Andrea Wells and Brad Cantwell with Arcadia Structured Settlements. Visit the Berkley Industrial Comp blog for these and more.

MSAs are complicated and confusing—they even stump the specialists at times. Sometimes you just need to talk to an expert in a certain area. If you ever have a question about an MSA, Dan is happy to talk to you. Get in touch with him at Daniel.anders@towermsa.com.

Medicare Set-Asides

Premier Webinar: Tricks of the Trade for Successful MSA Outcomes

July 5, 2022

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

MSA Second Opinion Success Story – $46,691 in savings

June 23, 2022

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!

MSA Optimization Yields $175,867 in Savings

June 15, 2022

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!

South Florida Business Journal Recognizes Tower MSA Partners as a Top 25 Women-Owned Business

June 9, 2022

banner featuring photo of CEO Rita Wilson and COO Kristine Dudley to announce Tower MSA being named to Women Owned Business list

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.

MSA 2nd Opinion Success Story – $98,120 in savings

June 7, 2022

nurse conducting research for a Medicare Set Aside Second Opinion in a manual

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:

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.
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.

Humana’s Brian Bargender Gives Tips on How to Work with Medicare Part C & D Plans

May 12, 2022

Attendees of Tower’s Premier Webinar on April 20 received sound advice on how to work with Medicare Part C (Advantage) and D (Drug Benefits) plans. Our guest presenter was Brian Bargender, Consultant, Subrogation and Third-Party Liability with Humana, a nationally recognized expert on these plans.

Bargender noted that these plans have the same rights and responsibilities as original Medicare under the Medicare Secondary Payer (MSP) Act. This means that Part C and D plans must avoid payment for treatment covered by primary payers, such as workers’ compensation or liability. Part C plans take this commitment seriously as they want to prove they are more efficient than original Medicare.

The PAID Act gave primary payers visibility into Medicare beneficiary enrollment status in Parts C and D. Previously, they could only see that an individual was enrolled in Medicare. It was problematic to identify a beneficiary’s plan and resolve conditional payments. The growing popularity of Medicare Advantage plans was making the process more time consuming. Approximately 46% of Medicare beneficiaries use Part C and 75% of the ones on original Medicare have Part D.

Bargender explained the plans’ approach to MSP compliance and touched on Private Cause of Action and Double Damages in the MSP Act. Medicare Advantage plans can obtain double damages from primary payers that refuse to reimburse conditional payments. And primary payers remain liable for repayment until plans are repaid, even if they have already paid the injured worker their settlement.

To make it easier to work with Part C and D plans in light of the PAID Act, Bargender offered these insights and advice:

While Section 111 reporting gives primary payers “an” address, it’s not necessarily the address the plan would have chosen. As such, further investigation into the appropriate plan contact may be necessary.
Medicare Advantage plans get Section 111 data, but not always in time to act on it. They use it as a back sweep to see if they missed anything.
Contact the plans before trying their recovery vendors; they have multiple vendors.
Ask for the subrogation or legal departments. Customer service reps at C and D plans are not well versed in Medicare Set-Asides.
It’s hard for Medicare Advantage and drug plans to predict and staff for call volume; prepare for delays.
The plan may not have the file when payers contact them.
It’s good for primary payers to notify the plan(s) when they accept responsibility for the claim, and certainly when they prepare for settlement. The Centers for Medicare and Medicaid Services (CMS) notifies plans later in the process.
To minimize calls and delays, provide plans the same information given to CMS for Ongoing Responsibility for Medical (ORM) or Total Payment Obligation to Claimant (TPOC) reporting along with the MSA diagnosis and prescription drug details if they are available.
At minimum, plans need this data:
- Medicare Beneficiary Identifier
- Name
- Date of birth
- Loss/Injury Date
Part C and D plans cannot correct errors in the file; these must be done through Section 111 reporting or through the Benefits Coordination and Recovery Center (BCRC).
These plans do not track how funds are used or exhausted. They need a letter from CMS to the MSA administrator or beneficiary that says funds were properly exhausted before they can start paying for injury care.

Tower has found Bargender and Humana’s subrogation team to be very helpful. They promptly identify specific reimbursement claim information when the claimant is enrolled in a Humana Medicare Advantage plan. Further, they are open to understanding the liability issues and basis for settlement; this is something not typically found with the Medicare conditional payment recovery contractors.

As Bargender stressed, “proactive beats reactive,” when it comes to resolution of these Part C and D claims. Primary payers must be proactive in using PAID Act data to identify whether a Medicare eligible claimant is enrolled in a MA plan, and, if so, investigate whether the plan is seeking reimbursement for payments it made on the claim.

For our Section 111 reporting clients, Tower has the PAID Act data readily available. Whether you are a reporting or non-reporting client, we can help you contact the Part C and/or D plan to investigate and resolve conditional payments at the time of settlement.

If you have questions or want a link to the recorded webinar, please contact Dan Anders at Daniel.anders@towermsa.com

Related articles

The PAID Act: Implementation and Implications for Claims Handling

Tower MSA Partners Receives 2022 SOC 2 Type II Attestation

May 3, 2022

Independent Audit Verifies Tower MSA Partners’ Internal Controls and Processes

Delray Beach, FL – Tower MSA Partners, a Medicare Secondary Payer compliance services company, today announced that it has completed its annual SOC 2 Type II audit, performed by KirkpatrickPrice. This attestation provides evidence that Tower has a strong commitment to security and to delivering high-quality services to its clients by demonstrating that they have the necessary internal controls and processes in place.

A SOC 2 audit provides an independent, third-party validation that a service organization’s information security practices meet industry standards stipulated by the AICPA. During the audit, a service organization’s non-financial reporting controls as they relate to security, availability, processing integrity, confidentiality, and privacy of a system are reviewed, examined and reported on. The SOC 2 report delivered by KirkpatrickPrice verifies the suitability of the design and operating effectiveness of Tower MSA Partners’s controls to consistently meet the standards for these criteria throughout the full audit period.

“The SOC 2 audit is based on the Trust Services Criteria,” said Joseph Kirkpatrick, President of KirkpatrickPrice. “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 Tower’s controls.”

“It’s an honor to again earn an unqualified 2022 SOC 2 Type II outcome” said Wilson. “It’s an attestation that Tower’s systems, policies and procedures meet the trust services criteria of security, availability, processing integrity, confidentiality, and privacy.”

What does this mean for you?

Peace of mind.
If you partner with Tower, you can be assured that
- Our human processes and our highly automated system– have been validated by third-party auditors after a stringent analysis.
- Your data is transferred safely, used appropriately, stored securely, and is accessible for the required amount of time.
- You can partner with a best-in-class MSP services provider and superior technology.
Cybersecurity assurance. Auditors recognized Tower’s commitment to keep up with cyber threats, patching, monitoring methods and cybersecurity technology. They saw that we monitor all internal systems for patching cadence and antivirus/antimalware activity, we regularly train staff on how to avoid the latest scams, and we execute multi-factor authentication and password changes to prevent breaches. In addition, we partner with reliable and well-respected cloud storage, monitoring, and security companies.

While the complete report is confidential and proprietary, a redacted synopsis of the report, SOC 3, can be downloaded here. I’m happy to answer questions and discuss the value of partnering with Tower for your MSP compliance and MSA needs. Please contact me at Rita.Wilson@TowerMSA.com to arrange for a conversation.