Category: Blog

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

May 20, 2021

a gavel and a magnifying glass to represent Medicare Set Aside settlement process

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

May 14, 2021

illustration of three nurses in scrubs for Nurses Month scrubs

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

May 11, 2021

bullhorn illustration alerting you to avoid reporting penalties

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

April 29, 2021

book marked by sticky notes illustrating changes Section 111 reporting on ORM

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

April 28, 2021

logo for AICPA. which conducts the SOC 2 Type II Audit

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

CMS Updates Section 111 Model Language Form

April 26, 2021

Man signing a document to illustrate CMS updates to Section 111 Model Language Form

Recently, the Section 111 Model Language form was updated by the Centers for Medicare and Medicaid Services (CMS), The form is used by Responsible Reporting Entities (RREs) to collect the Medicare Beneficiary Identifier (MBI) and/or a Social Security Number (SSN) from claimants.  The SSN or MBI, along with the claimant’s First and Last Name, Gender, and Date of Birth, are needed by the RRE to query CMS to determine whether the claimant is a Medicare beneficiary for Section 111 Mandatory Insurer Reporting purposes.

The most notable change to the form is that the Section I language was revised from “Are you presently, or have you ever been, enrolled in Medicare Part A or Part B?” to “Are you presently, or have you ever been, enrolled in Medicare?” We assume this language was modified because the claimant’s enrollment in Parts A, B, or C (which isn’t even mentioned) is irrelevant for purposes of Section 111 reporting. The simpler language, just asking for Medicare enrollment status, should avoid confusion that may have arisen from the prior language.

Practical Implications of the Section 111 Model Language form

As we wait for CMS to issue final rules around mandatory insurer reporting penalties, it is important for RREs and those administering claims for RREs to collect this identifying information or document their efforts to collect it by using this model language.  As we discussed in CMS Issues Proposed Rule for Mandatory Insurer Reporting Penalties, RREs will have a safe harbor from reporting penalties if they document good faith efforts to attempt to obtain an MBI or SSN from the claimant, and this model form will help document those efforts.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with comments or questions.

Related Posts

Section 111 Reporting

Dan Anders in WorkCompWire: Avoiding Section 111 Reporting Penalties

 

CMS Section 111 Mandatory Insurer Reporting Webinar Recap

April 7, 2021

man on keyboard for Section 111 Mandatory Insurer Reporting

Leaders from the Centers for Medicaid and Medicare Services (CMS) Division of MSP Program Operations, Commercial Repayment Center (CRC), and Benefits Coordination and Recovery Center (BCRC) held an April 1 webinar on the intersection of the BCRC and CRC in Section 111 Mandatory Insurer Reporting and the resolution of Medicare conditional payments.

While mostly a Q&A format, the webinar unveiled a new CMS/BCRC policy for reporting partial settlement of medical when Ongoing Responsibility for Medical (ORM) ends for certain diagnoses and continues for others. Set to rollout in June, the new reporting policy provides for three scenarios:

  • Partial settlement of medical prior to initial reporting

Scenario:  Claimant is identified as a Medicare beneficiary which triggers the requirement to report ORM and/or Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process.  Both ORM and TPOC are for the same insurance type, policy, and claim number.  The only difference is the accepted and denied diagnoses on the claim.  The parties agree to a partial settlement for the denied diagnoses and leave the accepted diagnoses open on the claim.

Problem:  How to report a partial settlement of the denied diagnoses and still report ORM for the accepted diagnoses.

 CMS Solution:  CMS’s solution is to submit two add records. Specifically, one record will be added for ORM that will describe all of the diagnoses that have been accepted for ORM.  ORM will be ‘Y’ with no TPOC date or amounts.  A second record will be added for TPOC which will describe all of the denied diagnoses that are being settled.  ORM will be ‘N’ with a TPOC date and amount.

  • Partial settlement of medical post initial reporting

Scenario:  A claim with multiple diagnoses was reported for ORM through the Section 111 Mandatory Insurer Reporting process.  The parties agree to a settlement for certain diagnoses while keeping ORM open for other diagnoses.

Problem:  How to report a partial settlement for certain diagnoses while keeping ORM open for the non-settled diagnoses.

CMS Solution:  CMS’s solution is to submit one update record and one add record.  The update record will remove the diagnoses that are subject to the partial settlement and keep the diagnoses codes where ORM continues.  Then, an add record with the TPOC date, amount and diagnoses codes that are subject to the partial settlement will be submitted.  ORM will remain “N” in the add record.

  • Partial ORM closure with no settlement

Scenario:  Acceptance of ORM is initially reported though the Section 111 Mandatory Insurer Reporting process with multiple diagnoses.  Subsequent to this initial report, there is a basis to terminate one or more of the initially accepted diagnoses, but not all of the diagnoses.  This is not a situation where a partial settlement has occurred, rather there is a basis to terminate one or more diagnoses absent a settlement.  For example, a claimant’s cardiac condition was exacerbated as a result of a fall and the medical providers confirm resolution of the exacerbation. While the carrier continues to accept the orthopedic condition, the ORM can end for the cardiac diagnosis.

Problem:  How to end ORM for one or more diagnoses while keeping it open for other diagnoses.

CMS Solution:  CMS’s solution is to send an update record that removes the diagnosis or diagnoses where ORM has ended. In this situation a TPOC date is not submitted, rather this is only submitted when ORM is completely terminated for all diagnoses.

The purpose behind these new policies is to improve coordination of benefits such that a Medicare beneficiary’s medical care is not denied when unrelated to a claim and prevent the recovery contractors from attempting to seek reimbursement for Medicare payments unrelated to a claim.

While we thank CMS and the BCRC for identifying solutions to the above reporting problems, we believe RREs may face some technical challenges in the ability to, for example, report two add records on the same claim.  We await issuance of the formal policy from CMS and will review how this policy change can best be incorporated into the Section 111 reporting process.

In addition to announcing the new reporting policy, CMS and the contractors provided the following advice:

Respond to correct contractor – Carefully review the correspondence and make sure to respond to the contractor that sent the letter, whether it’s to obtain further information, dispute/appeal charges, or to make payment.

As a reminder, CMS noted, the BCRC is generally recovering conditional payments when the identified debtor is the Medicare beneficiary while the CRC is recovering conditional payments when the insurer/WC carrier is the identified debtor.

CMS provided the following guidance regarding key timeframes:

  • Interest accrues from the date of the demand letter and is assessed on debt if not resolved within 60 days.
    • When CMS issues a demand letter directly to the applicable plan, the applicable plan has formal administrative appeal rights.
    • The applicable plan has 120 days from the date the applicable plan receives the demand letter to file a redetermination (first level of appeal). Interest will still accrue during this time.
    • If the appeal is not filed within 120 days, and “good cause” for untimely filing is not provided, the appeal will be dismissed.
    • Failure to resolve the debt will result in referral to treasury at 180 days.

Note:  When you are appealing to the ALJ please be sure to cc the CRC so that they can appropriately place a hold on a case so that it is not referred to treasury while the appeal is in process.

During the Q&A portion of the webinar CMS and its contractors addressed varied questions; some are summarized below:

  • What can be done if we cannot obtain a Social Security number from the claimant? CMS advised them to document their efforts at obtaining the SSN.  It was noted CMS has model language found on the CMS website which can be used to document claimant’s refusal to provide SSN.
  • In response to a question concerning the many charges found on conditional payment notices and demands that are unrelated to the injury, CMS/CRC acknowledged that it is not a perfect process. The CRC explained that when conditional payment information is requested what is sent to the requestor may have only been produced through an automated search of charges related to the injury.  CRC did advise that when it comes to actual issuance of a demand that there is a human validating process.
  • In response to a question concerning why in response to a dispute of a Conditional Payment Notice, one might receive another CPN with new charges, the CRC explained that this is the result of the system constantly reviewing for additional charges deemed related to the injury.
  • There were several questions regarding problems with the CRC recognizing out-of-pocket reimbursements to claimants in a no-fault/med-pay claim as counting towards the exhaustion of the no-fault maximum amount. CRC’s response was to advise entities to provide plan documents and proof of payment to the claimant along with a reason for the payment.  Its leader said, “We are aware that no-fault payors have run into problems with CRC rejecting out-of-pocket expenses as included within the no-fault exhaustion amount.”

If you have any questions, please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.

Related prior posts:

CMS RELEASES TECHNICAL UPDATES TO SECTION 111 USER GUIDE

Tower MSA Partners Ready to Steer Clients Through Pending Section 111 Civil Money Penalties

April 1, 2021

View from Dashboard over highway to illustrate Section 111 Civil Money Post

Last year the Centers for Medicare and Medicaid Services (CMS) proposed regulations on Section 111 civil money penalties (CMPs). See Tower MSA Partners’ detailed prior post, CMS issues Proposed Rule for Mandatory Insurer Reporting Penalties related to inaccurate or untimely Section 111 Medicare Mandatory Insurer Reporting. Some of these are shocking – up to $1,000 per day per claimant in some cases.  Tower and others in the Medicare Secondary Payer (MSP) industry collaborated on comments to CMS’s proposal.

Then, Tower went well beyond simply responding to CMS.  We took proactive measures to prepare our clients for the eventual penalties. We educated clients with a webinar focused specifically on the subject matter, and we have communicated frequently.

Tower’s proprietary tech tools help prevent Section 111 Civil Money Penalties

In addition to education and communication, with Tower’s focus on technology to measure, manage and drive results, we built a dashboard to steer our clients through MSP compliance so they can avoid CMPs when they go into effect.  See our news release for details: Tower MSA Partners Releases Medicare Mandatory Reporting Dashboard.

Our S111 Management Dashboard gives you the 24/7 data and reporting oversight for every aspect /of the reporting process.  Workers’ compensation and liability payers usually have limited visibility into claims history through their Section 111 providers’ reporting systems.  They may receive compliance error reports but aren’t able to quickly verify compliance accuracy.  Few systems remind responsible reporting entities to update the ongoing responsibility for medicals (ORM) termination dates when claims are settled.

The dashboard gives clients full visibility into their claims from a global level all the way down into the details of a specific claim.  You can manage the accuracy of data, such as ICD 10 codes or ORM to avoid unnecessary conditional payment or MSA exposure in addition to avoiding CMPs.

“The dashboard is intuitive and simple to use,” said Todd Venneri, Business Intelligence Project Manager for BETA Healthcare Group, who tested its features. “The ability to quickly access and verify claim information is invaluable.”

While our intuitive S111 Management Dashboard was being developed, we also updated our client portal and MSP Automation Suite. Keep in mind, Tower’s system was built specifically by us for this industry.  It seamlessly manages Section 111 reporting, conditional payments, Medicare Set-Aside triage, clinical and legal interventions, MSA preparation, and CMS submission activities that take clients through settlement and closure.

We don’t know when CMPs will be announced or how Section 111 civil money penalties will be assessed.  What we do know, however, is that our clear, concise dashboard has replaced uncertainty with knowledge and information.

We are ready and we want you to be ready, too.  If you have not used the dashboard yet, take it for a spin.  Get in touch with Hany Abdelsayed at hany.abdelsayed@towermsa.com or 916-878-8062 for a demo.

Women’s History Month: Celebrating Tower’s History as a Women-Owned Business

March 18, 2021

Portraits of Rita Wilson and Kristine Dudley. executive team of Tower, a women-owned business

As a women-owned business serving the workers’ compensation and liability insurance industry in the Medicare Set Aside (MSA) sector, we thought a great way to celebrate this month is to take a chapter from our own history. We’re pretty proud of our leadership team as well as being certified members of WBENC or the Women’s Business Enterprise National Council, a leading non-profit organization dedicated to helping women-owned businesses thrive.

Tower is not only a women-owned business, 85% of employees, including the majority of our managers and supervisors, are women.

The company was co-founded in 2011 by Rita Wilson and Kristine Wilson Dudley.

Tower Co-Founder: Rita Wilson

Rita’s path to Medicare Set-Asides wound through technology and pharmacy. She graduated summa cum laude with a BS degree from Presbyterian College in Clinton, SC, completed graduate studies at Converse College in Spartanburg, and started her tech career with a textile company.

She later became Director of Research & Development for a company that developed pharmacy management software. Her team developed standards for information exchange between group health pharmacy benefit managers (PBMs) and pharmacies. Her next move was to build out the operations and technology for a start-up workers’ comp PBM and ultimately become its CEO.

“We took insurance billing from a labor-intensive and mostly paper-bill environment into electronic adjudication,” Rita said.

In 2006, she moved to Florida and founded a diagnostic company and did some technology consulting with Speedy MSA, which was owned by Behn Wilson. He introduced Rita to his daughter, Kristie.

Tower Co-Founder: Kristine Wilson Dudley

Kristie had grown up in the workers’ comp industry and recalls going to the conference that is now WCI when she was just seven years old. Kristie went to the University of Tennessee at Chattanooga on a tennis scholarship, scoring the honor of NCAA Academic All-American in 2004.  She earned her law degree from Florida State University School of Law in Tallahassee.

She practiced law for a while, gaining workers’ comp experience with the firm of Eraclides & Gelman. While MSAs did come up, the firm saw them as necessary, but problematic. “And that’s still true with some law firms and even some adjusters today,” she said. “If you don’t do MSAs every day, they can seem like hurdles instead of opportunities to settle claims.”

While she liked practicing law, Kristie really wanted to operate a business. With Rita’s technology and pharmacy expertise, their joint understanding of MSAs, and Kristie’s legal background, the women knew they could offer deliver MSAs with a better balance of care, cost and compliance than any others in the market.

Tower MSA Facilitates Settlement

The MSA environment of the late 2000s was paper intensive, technology hungry and lacking structure, not unlike pharmacy billing before the ‘90s, according to Rita. It was hard to tell exactly what was happening at any given time with a claim and what action needed to be taken. Claims languished and collected unnecessary expenses.

“I had seen the birth of on-line pharmacy bill adjudication and the standardization of data transfer protocols and knew we could leverage technology to efficiently manage MSA production and approval processes, consistently execute workflow, drive results and accelerate settlements,” she said.

And so, these two women entered a mature market, developed a methodology that changed the paradigm as to how MSAs can facilitate settlement and created metrics to manage performance.  From the ground floor, Tower MSA Partners developed a sophisticated platform that targets cost drivers, documents recommendations of clinical and legal interventions, prompts next steps and keeps claims moving toward settlements.

Is Tower run by pushy women?

“Tower differentiates itself by aggressively seeking ways to mitigate costs and secure savings for clients,” Rita said. “Technology makes that possible.” Through claims feeds from clients, MSA specialists look for things that add unnecessary expense like possible surgeries that have not been discussed in a long time, prescriptions that were never filled, or brand drugs being used when generics could be.

“We’re different because we keep pushing.  We listen to what CMS says and we push back when we disagree with a finding, we bring evidence, we intervene.  We don’t just roll over,” Kristie insists. “Technology and measurements enable us to confidently do this.”

Is Tower run by pushy women? “We prefer ‘proactive,” Rita said, “but if the stiletto fits….”

If you’d like to connect with Rita or Kristie or Tower MSA Partners, email them at rita.wilson@towermsa.com or kristine.dudley@towermsa.com.

Related

Rita Wilson, Chief Executive Officer

Kristine M. Dudley, Esq., Chief Operations Officer

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

March 15, 2021

People sitting around conference table discussing MSA settlements.

Tower MSA Partners knows our strengths.  And we know our business.

We’re in the Medicare Set-Aside settlement business. Everything we do, we do to make workers’ compensation settlements possible — whether they have MSAs or not. Tower has built its business processes and technology around making settlements easier, faster, smoother, and less expensive.

We recognize that the value of an MSA is its ability to facilitate workers’ compensation and liability claim settlement and closure.  We also recognize that MSAs can become stumbling blocks to injured workers and their attorneys when it comes to settling claims.  Since Tower’s goal is to break through all barriers to settlement, we formed a strategic partnership with Ametros, the leader in the professional administration of Medicare Set-Asides.

Helping Injured Workers Settle Well

Ametros, which does not produce MSAs, helps injured individuals manage their Medicare Set-Asides and medical allocations after settlement.  During the settlement process, its team educates injured workers and their attorneys on their responsibilities and the resources available to them through professional administration after the settlement. Ametros frequently attends mediations and settlement conferences to help educate all parties on the post-settlement reality of managing a Medicare Set-Aside and how its services support compliance with Medicare Secondary Payer guidelines.

CareGuard, Ametros’ professional administration service, helps injured individuals navigate the healthcare system after settlement. CareGuard Members receive significant discounts for their injury-related medical and pharmacy expenses, durable medical equipment, home health care, and other services. Ametros handles the payment of all medical bills from their settlement funds and takes care of the Medicare reporting associated with an MSA.

Once injured workers understand they can have these services after they close their claims, they’re more likely to move forward to settle the case.

Many of Tower’s clients already work with Ametros and understand the value they bring. This made the idea of working with Ametros to simplify the settlement process for clients and adjusters a natural evolution.

Taking Work Off the Adjuster’s Desk

To further boost efficiency, Tower and Ametros developed a real-time electronic data interchange (EDI) to exchange MSA, CMS, and settlement data. MSA information is automatically updated directly in Ametros’ system at the time of MSA delivery to the client, enabling the Ametros team to begin educating the injured worker, their family, and attorneys.

This is another way we take work off adjusters’ desks and accelerate settlements that involve MSAs.

Speed Settlements

Recently, Tower launched a new program with Ametros to speed settlements. Using our powerful data analytics capabilities, Tower identifies claims that meet criteria for closure and creates a settlement candidate report. Ametros is then engaged to reach out to these injured workers or their attorneys to offer professional administration as an added benefit and to gauge interest in settlements.

When settlement is indicated, Tower prepares the MSA, executes all cost-mitigation strategies and postures the claim for closure.

This is an exciting new way to proactively address claims that may have slipped out of view and generate interest in settling.  There’s no extra work for adjusters and no cost for the payer until a claim is ready to settle and an MSA is prepared.

Future posts will share other strategic partnerships that Tower has forged to build a better, stronger Tower to help you efficiently and cost effectively settle claims.

Meanwhile, have Tower create an MSA settlement candidate report for you. To learn more, contact Hany Abdelsayed hany.abdelsayed@towermsa.com (916) 878-8062.

Rita Wilson

Chief Executive Officer

 

Related:

Legacy Claim Settlement Initiatives