December 22, 2020
This year has brought deeper meaning to traditional holiday wishes. We are thinking about our health, families, and partners in different ways and re-thinking priorities. But as we adapt to new realities, our commitment to you–our partners–is unwavering. Thank you for your loyalty during this challenging year.
We sincerely hope you enjoy a happy and healthy holiday.
Your friends at Tower MSA Partners
December 16, 2020
The recently enacted PAID Act ensures that insurance carriers have access to Medicare Advantage plan enrollment information
On December 11, 2020, President Trump signed into law HR 8900, Further Continuing Appropriations Act, 2021, which included the provisions of the Provide Accurate Information Directly Act or PAID Act (It is named Transparency of Medicare Secondary Payer Reporting Information in Section 1301 of the law).
What does all this mean? In short, the PAID Act requires the Centers for Medicare and Medicaid Services (CMS) provide applicable plans (liability insurance, no-fault insurance and workers compensation laws or plans) access to Medicare beneficiary enrollment status in Medicare Advantage and Part D Prescription Drug plans. Currently, this information can only be obtained from claimants which impedes the applicable plans’ efforts at mitigating their exposure to reimbursement claims from these Medicare Advantage and Part D plans.
Background on PAID Act
CMS has consistently asserted that Medicare Advantage and Part D plans have the same or similar rights of recovery under the Medicare Secondary Payer (MSP) Act as CMS itself. Federal courts have largely agreed with CMS’s position, notably finding Medicare Advantage plans can seek post-settlement reimbursement against applicable plans, including double damages.
Presently, the applicable plans do not have access to Medicare Advantage and Part D plan enrollment information. CMS claims statutory privacy limitations prevent it from providing access. Plans are forced to rely on claimants to voluntarily share their Medicare Advantage plan or Part D plan enrollment, an inconsistent and unreliable method.
To address this problem, a group of industry stakeholders, through the Medicare Advocacy Recovery Coalition (MARC), advocated for the PAID Act. The National Medicare Secondary Payer Network (formerly NAMSAP), in which Tower is a corporate partner and member, endorsed the bill in 2018.
The bill, now law, provides that if through the Section 111 query process the claimant is identified as a Medicare beneficiary, then CMS must also respond with the following:
Whether a claimant subject to the query is or during the preceding 3-year period has been, entitled to benefits under the program under this title on any basis; and
to the extent applicable, the plan name and address of any Medicare Advantage plan under part C and any prescription drug plan under part D in which the claimant is enrolled or has been enrolled during such period.
In other words, if the claimant has been enrolled in a Medicare Advantage or Part D plan in the prior three years, the applicable plan will have access to that information through the Section 111 Mandatory Insurer Reporting query process.
Practical Implications
We applaud the passage of the PAID Act, which will make it easier for payers to proactively identify and then investigate and resolve Medicare Advantage and Part D Prescription Drug plan reimbursement claims. As a result, claims can be settled with confidence that a reimbursement claim or lien will not pop-up weeks, months or years later.
CMS has one year after the date of enactment, that is December 11, 2021, to have the enhanced Section 111 query process in place. When Tower receives technical guidance on how this change will be incorporated into the current Medicare beneficiary query process, we will update our Section 111 reporting clients.
As always, if you have any questions, contact Dan Anders, Tower’s Chief Compliance Officer, at daniel.anders@towermsa.com or 888.331.4941.
Related:
CMS: PAID Act Implementation Guidance & New ORM Termination Option
WorkCompCentral Explains the PAID Act
December 14, 2020
Recently, the lowest average wholesale price of Celebrex 200mg and the price of multiple strengths of Abilify dropped dramatically resulting in major MSA reductions.
A widely used, non-steroidal anti-inflammatory drug, Celebrex (Celecoxib), is FDA-approved for several conditions:
Per Red Book, the lowest average wholesale price for Celecoxib 200mg dropped from $1.79 to $0.33, an 81.56% price reduction.
Abilify (Aripiprazole) is an antipsychotic drug FDA-approved for the following conditions:
Per Red Book, the lowest average wholesale price for multiple strengths (2mg to 30mg) of Aripiprazole dropped from the $30 to $36 range to a range of $0.07 to $0.17 per dose, an almost 100% price reduction.
Tower Action in Response
Because Tower’s system tracks all medications allocated in MSA reports, we have already pulled reports from the past two years that allocated these medications and advised clients of the potential for MSA reductions. You can also contact us to determine whether a particular MSA qualifies for MSA reductions. Revisions to the MSA can be done now or prior to MSA submission to CMS.
Please contact Dan Anders, Tower’s Chief Compliance Officer, at Daniel.anders@towermsa.com or (888) 331-4941 with questions.
December 1, 2020
In an 11/25/2020 Alert, the Centers for Medicare and Medicaid Services (CMS) announced that the 2021 conditional payment recovery threshold for liability, no-fault and workers’ compensation settlements will remain at $750. Accordingly, Total Payment Obligations to the Claimant, TPOCs, in the amount of $750 or less are not required to be reported to CMS through the Section 111 Mandatory Reporting process, nor will CMS attempt to recover conditional payments for TPOCs of this amount (The threshold does not apply to liability settlements for alleged ingestion, implantation or exposure cases).
By way of background, pursuant to the SMART Act of 2012, CMS is required to annually determine a threshold amount such that the cost of collection does not outstrip the amount recovered through such collection efforts. CMS’s calculations, which can be found here, resulted in maintaining the $750 threshold.
Practical Implications
As CMS is keeping the $750 threshold for mandatory reporting and conditional payment recovery there are no changes to the reporting processes or determinations as to when conditional payments should be investigated or resolved.
Related
Questions About Medicare Conditional Payments? Join Our Upcoming Free Webinar
November CMS Mandatory Reporting and Conditional Payment Updates
November 24, 2020
Here’s a recap of recently announced CMS news:
CMS News #1: Medicare Conditional Payment Appeals Guide
In follow-up to its September 2020 webinar on Medicare conditional payment appeals through the Commercial Repayment Center (CRC), CMS converted the slides into an appeals guide. The guide, which can be found here, provides a breakdown of the Medicare conditional payment appeals process and the bases for appeals.
CMS News #2: Updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Guide
Earlier in November, CMS released a Technical Alert and an updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting User Guide, Version 6.1, to announce “Section 111 Edits to no Longer Cause Record to Reject.”
In short, starting April 5, 2021, several error codes will be converted into what CMS calls “soft edits.” Soft edits are still considered errors by CMS but will not cause the entire record to be rejected. Examples of such data errors are in fields reporting middle initial of claimant’s name and alleged cause of injury. The Responsible Reporting Entity (RRE) is still responsible for correcting these errors in the next quarterly file submission.
Additionally, a new soft edit will be added and applied to NGHP Claim Input File Detail Record files when users submit a no-fault insurance claim where the policy limit is less than $1000.00. The input files will be accepted but a new CP13 error will be returned on the response files.
Finally, Claim Input File Detail Records submitted prior to the effective date of the injured party’s entitlement to Medicare will be rejected and returned with a Disposition Code ‘03’ instead of an SP31 error. As a result, if the purpose of the report was to indicate ongoing responsibility for medicals has been accepted (ORM=Y), then the claim will need to be re-submitted in the next quarterly reporting period (at which point the claimant is presumably entitled to Medicare).
CMS News #3: CMS to Host BCRC Recovery Process Webinar
On Wednesday, December 9, 2020 at 1:00 PM ET, CMS will be hosting a webinar focused on the Medicare Secondary Payer (MSP) recovery process when a Medicare beneficiary receives a settlement, judgment, award, or other payment. In other words, following its September webinar featuring the CRC, CMS is now highlighting the work of its Benefits Coordination and Recovery Center (BCRC). The announcement can be found here.
Per the announcement:
The primary intended audience is attorneys who represent beneficiaries and other beneficiary representatives. The BCRC will present a refresher on the beneficiary recovery process, including what functions can be facilitated using the Medicare Secondary Payer Recovery Portal (MSPRP). Such functions include submission of authorizations, requesting a Final Conditional Payment, and electronic payments. The webinar will also discuss alternative demand calculation options (Self-Calculated Conditional Payment Amount and Fixed Percentage Option), as well as other beneficiary recovery tips and best practices. The presentation will be followed by a question and answer session with participants.
We encourage anyone who is new to Medicare conditional payment recovery through the BCRC or would like, as CMS indicates, a refresher, to attend the webinar.
If you have any questions regarding these announcements, please contact Tower’s chief compliance officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.
Related:
CMS to Host Reporting and Medicare Conditional Payment Recovery Town Hall
$750 Medicare Conditional Payment Recovery Threshold Remains for 2021
CMS Introduces Pre-CPNs and Open Debt Reports in Conditional Payment Recovery Process
October 30, 2020
Tower’s cybersecurity partners, Avertium and Vigilant, have advised us of a major ransomware attack, primarily targeting the healthcare sector. The threat actor, known as “Ryuk,” uses phishing e-mails to gain access and then control of the victim’s computer and ultimately the company’s network. Once in control, files are encrypted and only decrypted in exchange for a “ransom.”
Avertium sent Tower this joint cybersecurity advisory from the Cybersecurity and Infrastructure Security Agency (CISA), the Federal Bureau of Investigation (FBI), and the Department of Health and Human Services (HHS) detailing a resurgence of this threat. Avertium also provided its cyber intelligence report which includes information on the attack and preventive measures.
Tower’s Response to Ransomware Threats
As a company that works directly with the healthcare sector, protection of our client’s information is critical to our Medicare Secondary Payer compliance services. Consequently, upon receiving the report of the Ryuk threat we immediately contacted our cybersecurity partner, Vigilant Technology Solutions, to confirm protections are in place to counteract any threats to Tower’s system.
Vigilant assured us that cybersecurity best practices are in place. First, its CyberDNA solution actively monitors Tower’s data traffic 24/7 and responds to threats in real time. Second, our network-installed McAfee Endpoint Protection (MEP) identifies a potential threat as early as possible and prevents the threat from entering the network or database. Third, our IT pros have previously taken the following recommended actions to keep customer data secure:
We urge our clients to confirm the above preventive measures are in place for their own network security.
For more detailed information on preventing ransomware attacks, CISA provides an updated guide which can be found here. If you have any questions regarding Tower’s cybersecurity program, please contact Jesse Shade, VP of Information Technology at jesse.shade@towermsa.com or 888.331.4941.
October 28, 2020
Seeking the formula for success in settling work comp cases with Medicare Set Asides (MSAs)? We’ve got you covered.
A Chinese proverb says, “The temptation to quit will be greatest just before you are about to succeed.” For workers’ compensation practitioners case closure represents success. However, the impediments presented by the need for an MSA to close a case often are a temptation to quit when success is within your grasp.
On Thursday, November 18 at 2:00 PM ET, Tower’s Chief Operations Officer, Kristine Dudley and Chief Compliance Officer, Dan Anders, will be joined by special guest, Nicole Chapelle, VP of Settlement Solutions for Ametros, to provide the formula for success in settling work comp cases with MSAs.
Here’s just some of what you will learn:
You will also learn that all of this can be done without increasing your work in successfully resolving the case.
A Q&A session will follow the presentation. Please click the link below and register today!
October 27, 2020
Has a Medicare Set Aside ever disrupted one of your settlements? Any one of these things — unexpected medical, surgical or pharmacy costs, compliance issues, the way MSA administration will be handled, or the presence or absence of a structured settlement–can halt negotiations.
Tower addresses cost drivers and deals with compliance situations long before preparing an MSA, so our clients don’t have to worry about MSAs impeding settlements and injured workers can be assured that their future medical needs will be met .
However, recently we’ve been asked to review MSAs prepared by other companies and found significant cost drivers and other obstacles to settlements. Fortunately, our free Medicare Set Aside Second Opinion service saved the settlements and helped to secure claim closures.
Medicare Set Aside Second Opinion Case Study
Here’s one case. Based on her experience with managing a claim and its costs, an adjuster thought the $220,000 MSA produced by another MSP provider was too high and asked us to review it.
Following our standard workflow for new MSAs, our Intake Team compared the MSA’s “accepted body parts” against the client’s claim system and found significant discrepancies.
The MSA allocated for a lifetime’s supply of sertraline, a drug used to treat anxiety and depression. However, “psyche/stress” was not an accepted body part and the workers’ comp insurer had not been paying for it.
Tower drafted a Body Part Letter that clarified the compensable conditions and specified those that were not accepted by or paid for by the insurer. Removing the drug from the allocation saved more than $58,000.
This 2nd Opinion review also detected recommendations for inappropriate medical treatment, including an unnecessary bladder surgery. Our Physician Follow Up Service – available at no extra cost to our clients – contacted the physician and obtained written confirmation of this, reducing the allocation by another $37,000+. We also obtained a rated age from K.P. Underwriting that further reduced the treatment and prescription cost over life expectancy. The total savings came to over $98,000.
MSA Value is in Claim Closure
How could we do this when the other provider couldn’t? It comes down to our philosophy and attitude.
Tower does not treat MSAs as commodities. Instead, we recognize that the real business value of an MSA is in its ability to facilitate claim settlement and closure.
Our role is to collaborate with clients to analyze and assess risk, review medical and pharmacy records to determine Medicare exposure, intervene when treatment changes are needed, and recommend the appropriate time to complete the MSA.
In short, we proactively work to reduce costs and posture files for settlement.
How We Achieve Settlement Success
We created MSA best-practices technology and continually update it to make sure we can always accurately allocate the MSA without overfunding. Our MSP Automation Suite contains the very latest CMS coverage, coding and individual state pricing data. We measure everything and analyze CMS responses line by line so we know what the agency will accept, what it won’t and when to push.
We know where cost drivers tend to hide, and our Intake and Clinical Teams are trained to hunt them down. We know which interventions to apply at the right time to reduce costs. We know how to phrase treatment and pharmacy changes and supply the precise documentation CMS needs to approve the MSA.
And we do all this the first time around, so you won’t need a second opinion.
With Tower, payers can enter settlement negotiations with realistic MSAs that they can explain and defend. (We’ll participate in these negotiations if you’d like.)
Settle well the first time with Tower. But, if you have a questionable MSA, let us give you our free 2nd opinion. Download more information here or refer an MSA for a 2nd Opinion by contacting our Intake Team at 888-331-4941 or referrals@towermsa.com.
October 22, 2020
Earlier this month CMS released an updated MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting User Guide (Version 6.0). Here are the key updates with analysis and practical implications.
Additional Definition of Total Payment Obligation to Claimant (TPOC)
Section 6.4 of Volume 3 (Policy Guidance) of the user guide defines TPOC this way:
The TPOC Amount refers to the dollar amount of a settlement, judgment, award, or other payment in addition to or apart from ORM. [Ongoing Responsibilities for Medicals] A TPOC generally reflects a “one-time” or “lump sum” settlement, judgment, award, or other payment intended to resolve or partially resolve a claim. It is the dollar amount of the total payment obligation to, or on behalf of the injured party in connection with the settlement, judgment, award, or other payment. Individual reimbursements paid for specific medical claims submitted to an RRE [Responsible Reporting Entity], paid due the RRE’s ORM for the claim, do not constitute separate TPOC amounts.
The update added an explanation of the TPOC amount computation to this definition:
The computation of the TPOC amount includes, but is not limited to, all Medicare covered and
non-covered medical expenses related to the claim(s), indemnity (lost wages, property damages, etc.), attorney fees, set-aside amount (if applicable), payout totals for all annuities rather than cost or present values, settlement advances, lien payments (including repayment of Medicare conditional payments), and amounts forgiven by the carrier/insurer.
CMS’s definition seems to have been largely pulled from the Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide’s definition of total settlement. Its purpose in the WCMSA Reference Guide is to determine whether a settlement meets CMS MSA review thresholds. While we assume CMS’s intent is to help reporting entities better determine the TPOC amount, adding this computation definition raises some concerns:
We see using the amounts forgiven term as a way for CMS to provide settling parties the ability to obtain an MSA approval when the WC case is settling and all or most of the settlement funds are coming from a 3rd party liability settlement. However, in the mandatory reporting context, amounts forgiven is a specific dollar amount which must reported and thus becomes relevant to Medicare conditional payment recovery
Were the WC carrier to report amounts forgiven in the TPOC amount, CMS and its recovery contractor would assume that the injured worker has received these funds as part of the WC settlement, which is not the case. These funds are not a payment to the claimant. The injured worker presumably receives payment from the 3rd party liability settlement and, if he or she was a Medicare beneficiary at the time of that settlement, this will be reported to Medicare. Requiring the WC carrier to report amounts forgiven in settlement and then having the liability carrier report the liability settlement is duplicative and unnecessary to protect Medicare’s interests. We hope CMS reconsiders the use of this terminology in its TPOC computation or clarifies what they mean by amounts forgiven.
Indemnity-Only Settlements are Not Reportable
Following its August 13, 2020 webinar on Section 111 reporting where CMS officials reiterated that indemnity-only settlements are not reportable as TPOC, CMS has now added the following to Section 6.5.1 of the guide, which also incorporates “property damage only” claims:
RREs are not required to report liability insurance (including self-insurance) settlements, judgments, awards or other payments for “property damage only” claims which did not claim and/or release medicals or have the effect of releasing medicals. Similarly, “indemnity-only” settlements, which seek to compensate for non-medical damages, should not be reported. The critical variable to consider is whether or not a settlement releases or has the effect of releasing medicals. If it does, regardless of the allocation (or lack thereof), the settlement must be reported.
This raises the question of whether a prior indemnity-only settlement amount is combined with a later settlement releasing medicals and reported as TPOC. As mentioned earlier, CMS’s TPOC computation definition was taken from the CMS WCMSA Reference Guide and applied to the TPOC computation. In doing so, CMS excluded the phrase “prior settlements of the same claim” to the TPOC definition. Based on this exclusion, which is consistent with other guidance in the user guide, we accept that a prior indemnity-only settlement is not reported as TPOC, even when a later settlement releases medicals.
If you have any questions, please contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.
October 14, 2020
In a recent update to its WCMSA Reference Guide, the Centers for Medicare and Medicaid Services released a state-by-state list of the major medical centers it uses for pricing future medical expenses in proposed MSAs. This zip code-based list (See Appendix 7 of the guide) will help MSA preparers and submitters more accurately price surgical procedures, including spinal cord stimulators and intrathecal pumps, per CMS requirements.
Background
From the reference guide:
Hospital fee schedules are currently determined using the Diagnosis-Related Groups (DRG) payment for the median major medical center within the appropriate fee jurisdiction for the pricing ZIP code, unless otherwise defined by state law (see Appendix 7).
While that sounds good, until this update, no one but CMS and the Workers’ Compensation Review Center (WCRC), which reviews submitted MSAs for CMS, knew for certain the major medical center.
Nonetheless, Tower’s experienced clinical team has historically been successful in identifying appropriate facility pricing, thus avoiding significant variances between the proposed surgical pricing and the CMS calculation. The release of the list removes any remaining uncertainty.
Practical Implications
The list of major medical centers should eliminate one area of variances in surgical pricing. (Variances can still occur based upon differences in the type of surgery allocated or the components of the allocated surgery.) In short, it should lead to more accurate pricing surgical procedures in proposed MSAs and reduce MSA counter-highers.
The list of major medical centers has been published as part of the reference guide and also within the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP).
As a member of the National Alliance of Medicare Set-Aside Professionals, now the National MSP Network (MSPN), Tower has consistently advocated for the release of this list. We appreciate the efforts of MSPN leadership to pursue this with CMS management.
A big thank you to Steve Forry and John Jenkins at the CMS Division of MSP Program Operations and to the WCRC for their work to assemble and release this information for public use.
If you have any questions, please contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.
