Tower’s Legacy Claims to Settlement Initiative identifies claims that can settle now or with intervention and produces smooth, efficient settlements.

Legacy claims. Old dog claims. Whatever you call them, these are the claims that languish on the books and just won’t close for any number of reasons.  If you missed Tower’s webinar hosted by Hany Abdelsayed, EVP of Strategic Services last month, here is a synopsis:

Legacy Claims Defined

Legacy claims can fall into one of several categories:

• Long-term open medical claims
• Run-off claims
• Claims from mergers and acquisitions
• Claims in a guaranteed cost program
• Loss portfolio transfers
• Non-acute cases with a high monthly medical and/or prescription drug spend

Often, legacy claims are left in the rear-view mirror as claims representatives take on new claims.  Sometimes, the injured worker or their attorney has an issue that needs to be addressed or the anticipated high cost of the Medicare Set-Aside stops the insurance carrier or employer from heading to the settlement table.  However, these legacy claims can represent significant reserves and liability for these payers that impact their entire workers’ compensation programs.

Tower’s Legacy Claims Initiatives service reviews your portfolio and identifies claims that have the potential to close, both those that that can close immediately and those that can close with intervention. We provide interventions for those that need them, customizing them to your needs and workflows.  We also identify claims that have no possibility of settling and position those for ongoing cost reduction. As the settlement project manager, Tower assembles a team with our partner professional administration Ametros and a structured settlement broker to smoothly and efficiently bring your legacy claims to closure.

We know that an MSA’s cost can pose a barrier to settlement. And we know exactly how to reduce unnecessary medical and pharmacy costs.  When scrutinizing medical records, we often find inappropriate use of opioids, muscle relaxants and benzodiazepines, often with multiple prescribers. Our free Physician Follow-up service contacts treating physicians and obtains written changes to the drug regimen. In addition, the switch of brand drugs to generics and verification of discontinued drugs and confirmation of ongoing treatment when properly documented so Medicare can approve the MSA, can result in thousands of dollars of savings on claims.

Injured workers and their attorneys can also be reluctant to settle claims.  This is where Tower’s partner Ametros, as the MSA professional administrator, can step in to talk with the injured worker and their attorney to allay any concerns they may have with closing out medical care and utilizing the MSA for future treatment.  Ametros provides medical and pharmaceutical discounts and has 24/7 care advocates available to help injured parties find providers. While injured workers often complain about the workers’ comp system, some don’t want to lose their adjusters help navigating the healthcare system, and Ametros gives them that post-settlement support.  Structured settlements help people who are afraid of spending all their money in a few years.  Tower, Ametros and the structured settlement broker also may attend mediahttps://ametros.com/tions when in-person settlements return.

When injured workers and their attorneys understand the post-settlement benefits available Ametros and structured settlement partners, they often agree to settle.

Results:

 In a settlement initiative for a large national employer, Tower and its partners were able to work with the client to settle cases with MSAs that resulted in a 43% reduction in open claims and 26% reduction in total claim costs along with a 55% reduction in CMS-approved MSA amounts compared to prior MSAs.

In a current settlement initiative started in March 2021, so far 23% of pursued claims have been settled with $60K in MSA savings because of Tower interventions.

Goal is Claim Closure

Keeping claims open is usually not the answer.  At no cost, Tower is ready to assist you as your project champion in selecting the right partners for the legacy claim settlement project and developing a plan which is customized to your type of claims and your claims team.  Further, this plan will identify and implement interventions to mitigate the MSA amount and alleviate the injured workers’ concerns in closing out their medical.

For more information or to consult on a potential legacy claims project, please contact Hany Abdelsayed at (916) 878-8062 or hany.abdelsayed@towermsa.com.

Tower’s free Physician Follow-up service is one of our most effective tools for reducing your MSA costs. This case history offers a deeper dive on how we use this tool.

Physicians often need to try different medications as they search for the best way to manage pain, and medical records do not always show that drugs had been discontinued. That happened in a case where the initial Medicare Set-Aside exposure was $285,181.

Physician Follow-up Case Study

An injured worker suffered from low back pain along with significant pain in his groin, hip, and left knee. By the time it came to settle the case, he was seeing a pain management specialist and benefiting from oral opiates and injection therapy.

Tower’s review of his medical records detected Amrix, Celebrex, and Amitriptyline as potential unnecessary cost drivers.  We recommended having our Physician Follow-up service contact the treating physician to confirm the current drug regimen and, if appropriate, document clarifications to the medical records.

First, our Physician Follow-up professionals determined that the drug regimen for the work injury was limited to oxycodone/APAP 5/325mg BID and three injections per year and that all other medications listed in the medical records had been discontinued. Then, following the state’s jurisdictional requirements, they drafted an attestation letter stating this and obtained the doctor’s signature.

By scrutinizing the medical records and properly wording and documenting the statement, Tower submitted an MSA of $53,664 to CMS.  CMS approved the MSA within nine days with no development letter or counter-higher for a savings of $231,487.

Physician Follow-up is Comprehensive

Tower’s Physician Follow-up addresses open-ended, ambiguous and contradictory medical records and can replace a physician peer review in many cases.  With client approval and per jurisdictional requirements our team will contact the treating physician(s) to:

• Clarify ambiguous medical treatment
• Find out if procedures, surgeries, or other therapies are still being considered
• Share information about multiple prescribers or pharmacies and duplicative or very similar medications
• Discuss high doses of opioids and other addictive drugs
• Ask the provider to consider tapering programs and alternative pain management options
• Determine the current frequency of urine drug tests if applicable
• Confirm the discontinuance of medications
• Request a switch from brand drugs to generics
• Obtain the last treatment date
• Confirm the current injury-related drug regimen

This an area where Tower excels.  We obtain the doctor’s statement in language that is clear, concise and in a format acceptable to CMS.  Notably, 83% of the MSAs we submitted in 2020 were approved with no Development Letters.  Next time there’s an opportunity to use our Physician Follow-up service, do it.  There’s nothing to lose and a lot to save.

To see this and some of our other case studies, go to Successes, and if you need help with settling the claim right now, get in touch with Hany Abdelsayed, hany.abdelsayed@towermsa.com, (916) 878-8062.

The Centers for Medicare and Medicaid Services (CMS) has issued guidance for the implementation of the PAID Act.  The agency also announced criteria for an additional option for the termination of Ongoing Responsibility for Medicals (ORM) in the Section 111 reporting process.

PAID Act Implementation

On June 8, 2021, CMS issued a Technical Alert on the implementation of the PAID Act.  The PAID Act (See Paid Act Becomes Law) will provide Responsible Reporting Entities (RREs), namely liability insurance (including self-insurance), no-fault insurance and workers compensation plans and insurers, Medicare Part C and D enrollment information for claimants identified as Medicare beneficiaries.  Starting December 11, 2021, the following information will be provided in the NGHP Section 111 Query Response File where CMS responds to a query about a claimant’s status as a Medicare beneficiary:

• Contract number
• Contract name
• Plan benefit package number
• Plan address
• Effective dates for the previous 3 years (up to 12 instances each for Part C and for Part D)

CMS also released an updated NGHP User Guide, Version 6.4, which provides the technical information for the query response file layout additions that will be required to receive this information through the query process.

Our Section 111 reporting team is reviewing the technical changes and will provide guidance to our reporting clients regarding system updates that need to be made before December 11, 2021, to enable receipt of the new field data.  We will also participate in testing, which CMS says will be available by this coming September 13.  Finally, we will attend CMS’s June 23 webinar on the PAID Act implementation and provide a summary of any relevant information.

Additional Option for ORM Termination

Besides the PAID Act, the updated Section 111 User Guide provides a new option for ORM termination.  Per Section 6.3.2 of the Section 111 User Guide (Policy Guidance), once ORM is accepted on a claim it can only be terminated if certain criteria are met:

• Where there is no practical likelihood of associated future medical treatment, an RRE may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
•  Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;
•  Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.

CMS has now provided additional criteria which allow ORM termination:

Where there is no practical likelihood of associated future medical treatment, which is reflected by meeting ALL of the following:

• No claims were paid with any diagnoses codes related to alleged ingestion, implantation, or exposure; and
• No claims were paid, for any medical item or service related to the case, within five (5) years of the date of service of any such claim; and
• Treatment did not include, nor were any claims paid related to, a medical implantation or prosthetic device; and
• The total amount paid by the insurer, for all medical claims related to the case, did not exceed $25,000.

Note: If, at any time, any of the parameters set forth above should no longer be applicable, the insurer must then update the ORM record to reflect that they, once again, have ongoing responsibility for medicals (i.e., update the termination date to all zeroes). Should the case once again fall under these parameters (for example, if five years elapse from the last relevant date of service), then ORM for that case may once again be terminated in accordance with the criteria above.

This policy gives RREs the ability to terminate ORM or not report ORM in the first place on minor medical claims.  We recommend a review of all outstanding claims with an open ORM that could fit these criteria to decide whether an ORM termination date should be entered.

For example, a Medicare beneficiary claimant has a traumatic injury on February 1, 2014.  Acceptance of ORM was reported through the Section 111 reporting process.  The last medical paid was for a date of service of March 1, 2016, where the total paid on the claim was $10,000.  On March 1, 2021, five years have passed and ORM may be terminated. Note, if the claim is later settled, the settlement amount would still need to be reported as Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process.

In addition to claims where ORM is currently open, this policy would apply to claims where potential ORM acceptance reporting was triggered because a claimant was identified as a Medicare beneficiary.

For example, the last medical paid in a traumatic injury was for a date of service of March 1, 2016, where the total paid on the claim was $10,000.  Medical remains open on the claim per state law.  The claimant became a Medicare beneficiary on June 1, 2021.  Per this policy, ORM acceptance would not need to be reported because all criteria have been met.  Note, like in the example above, if the claim were to settle, the settlement amount would need to be reported as Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process.

If you have questions about the PAID Act or the changes to ORM reporting, please let me know.  Contact me at daniel.anders@towermsa.com or 888.331.4941

 Related Prior Posts:

CMS to Host Paid Act Webinar