Blog Archives

PAID Act Becomes Law

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.

WorkCompCentral Explains the PAID Act

Celebrex and Abilify Price Drops Trigger MSA Reductions

December 14, 2020

Vial of pills illustrating MSA Reductions in RX costs

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:

Ankylosing spondylitis
Juvenile rheumatoid arthritis
Acute migraines
Osteoarthritis
Acute pain
Primary dysmenorrhea
Rheumatoid arthritis

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:

Schizophrenia
Acute treatment of manic and mixed episodes associated with bipolar
Adjunctive treatment of major depressive disorder
Irritability associated with autistic disorder
Treatment of Tourette’s disorder

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.

Medicare Conditional Payment Recovery Threshold for 2021

December 1, 2020

chart, dollars and a fountain pen illustrating conditional paument recovery threshold post

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.

November CMS Mandatory Reporting and Conditional Payment Updates

November CMS News: Mandatory Reporting and Conditional Payment Updates

November 24, 2020

Hand writing What's New?" on a chalkboard for CMS news update

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.

$750 Medicare Conditional Payment Recovery Threshold Remains for 2021

CMS Introduces Pre-CPNs and Open Debt Reports in Conditional Payment Recovery Process

New Ransomware Attack Threatens Healthcare Sector

October 30, 2020

threatening hooded figure with the word cyber security superimposed to illustrate post on best practices for cybersecurity

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:

Ensure MEP is fully deployed to all applicable/at risk assets within your environment
Provide security awareness communications to employees as a reminder to be mindful during day-to-day activity:
- Never open unsolicited emails and their attachments.
- Be wary of suspicious looking advertisements.
- Limit / avoid the use of personal email on company assets.
Regularly update infrastructure (both operating system and application software) with the latest patches to ensure full coverage in addition to updated McAfee Anti-Virus software.
Ensure backups of data/records are regularly performed and available.

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.

WEBINAR – Grasp Success in Settling Work Comp Cases

October 28, 2020

banner promoting Tower webinar on settling work comp cases

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:

The latest on ways Medicare makes CMS MSA approval difficult or drives up MSA costs and how to meet these challenges.

Straightforward clinical interventions and case settlement strategies which reduce the MSA amount and allow for quick CMS MSA approval.

Easing the settlement concerns of the injured worker by transitioning to MSA professional administration or self-administration assistance for future medical care.

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!

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

Need a Medicare Set Aside Second Opinion?

October 27, 2020

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

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 2^nd 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 2^nd opinion. 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.

CMS Rolls Out Updates to NGHP User Guide

October 22, 2020

CMS User Guides for Section 111 Reporting. open book with colored page markers

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:

Liens & Medicare Conditional Payments: In some cases, lien payments, including the Medicare repayment conditional payment amount, is not known at the time of settlement. This is not a problem if the injured worker is repaying Medicare out of the settlement amount. But it may be a problem if the employer or carrier is agreeing to pay Medicare with funds outside of the settlement amount because they may not have a final demand amount prior to settlement. Our solution would be for CMS to clarify that a lien payment, namely a repayment of Medicare conditional payments made directly to Medicare or to a lienholder, Medicaid for example, is not part of the TPOC computation.

Amounts Forgiven in Settlement: Besides repayment of liens, CMS also brings in the term “amounts forgiven” from the WCMSA definition of settlement. While it has never been further defined in the CMS WCMSA Reference Guide and CMS provides no further clarification here, the general understanding is that this refers to the carrier or employer’s waiver of a subrogation lien against a 3^rd party liability settlement. An employer or carrier may waive their subrogation lien for many reasons, and they may do so without having a firm dollar amount to even determine the “amounts forgiven.”

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 3^rd 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 3^rd 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.

CMS Adds New Pricing Resource to WCMSA Reference Guide

October 14, 2020

stethescope on a Workers’ Compensation Medicare Set-Aside Arrangements

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.

What Gets Measured Gets Managed…. What’s Your Number?

October 12, 2020

graphic with Peter Drucker quotation on metrics: "What gets measured gets managed"

We passionately focus on metrics – it’s our driving force in making Tower Measurably Better.

In today’s digital environment, if you are an employer, carrier or TPA, you are likely inundated with data. You get claims data, medical and pharmacy data, predictive analytics, benchmark performance data, claim reports, drug interaction, duplicate therapy and contraindication notices, even drug triggers like poly-pharmacy notices, opioid utilization reports, and morphine equivalent dosage (MED) outliers. You digest voluminous amounts of data internally and also receive a plethora of reports from your vendor partners. With access to so much data, how do you aggregate it into its simplest form, drilling down to the information that actually shows how you’re doing? Whether you call it ‘key performance indicators”(KPIs) or use some other business term, the short answer is “metrics.”

In the words of Peter Drucker, “You can’t manage what you don’t measure.”

As a company that deals with volumes of data internally, and as we work to support our clients’ efforts to comply with the MSP statute, Tower is all about metrics and continuous improvement. Metrics drive internal efficiency improvements, workflow changes to streamline processes and the implementation of technology enhancements to improve our work product and turnaround times. It’s also how we bring added value to clients to optimize MSA outcomes. We define, measure and manage the metrics that yield the ”best” balance in care, cost, and compliance and we use these key performance indicators to reverse engineer MSA preparation methodology to continuously improve MSA, CMS approval and settlement outcomes. We identify the metrics that drive the results we want to see. We then measure our performance and modify processes, workflow, and technology to improve.

METRICS TELL A SIMPLE STORY

Step #1 is to identify what drives the results you seek to achieve. For example, in the case of the MSA and settlement, most would agree that pharmacy is the single biggest cost driver. We’ve heard this from clients through the years and we’ve monitored this issue ourselves. Though prescription drug costs have come down over the past year, pharmacy remains the biggest concern expressed by payers when settling claims that involve an MSA. Yet if asked, would you know what percent of your CMS approved MSAs include opioids, the percent of MSAs that include any pharmacy, or the average cost of prescription drugs on MSAs. You can manage (improve) only what you are measuring.

Measuring 2019 performance in Tower’s total book of business as it relates to CMS approved MSAs and pharmacy costs,

57% of CMS approved MSAs with ongoing medical had $0 allocated for pharmacy;

78% of CMS approved MSAs with ongoing medical had $0 allocated for opioids.

We know what drives the results we want to see and we know where we are today. We’ve measured these metrics for the past 3 years, and continue to monitor to see how we can improve.

ONCE YOU MEASURE, HOW DO YOU MANAGE?

Tower’s clinical staff constantly examines current CMS performance against the latest state workers’ compensation statutes and associated fee schedules, then overlay this with CMS’s review methodology as defined in the most current WCMSA Reference Guide. When changes are found, updates are immediately loaded into our system, verified and released. Getting this process in place took a great deal of time, effort, and technology support, but it was key to our ability to measure performance. Once in place, it’s now a simple verification, audit and sign-off process each month.

In addition to monitoring external changes, our system also benchmarks every CMS response against our internal best practices in MSA allocation. This is done by reconciling every line item in every CMS response. Through this software module, we know exactly how we perform against CMS in pricing, frequency, life expectancy, etc. This information is stored in real time for every response every day, not via a month-end report or only when there’s a Counter Higher response. Our system prompts our staff to review and reconcile each CMS response immediately upon upload.

Through our proactive approach to clinical and pricing methodology and our CMS response measurements, we avoid overfunding when we initially draft the MSA. We are also able to reverse engineer to identify cost drivers and barriers to settlement as part of case triage. We know which clinical and legal interventions can mitigate exposure because we have the historical benchmarks that measure these results historically.

In tracking CMS results over the past 3 years, CMS MSA dollars continue to go down through consistent execution of Tower’s pre-MSA intervention / physician contact process

In 2019, our pre-MSA intervention model yielded CMS approved MSA savings of 53.3% when initiated before CMS submission.

We’ve also identified the documentation/evidence CMS requires in order to approve changes in medical treatment and reductions/discontinuations in drug therapy and we obtain this up front.

With historical benchmarks and CMS performance data, we can easily discern when we have a basis to challenge CMS via re-review submission, and we know what clinical, statutory and pricing documentation to provide to support our request. In measuring our CMS re-review performance for all CMS counter higher responses received in 2019,

Average turnaround time for Re-review determination and submission was <48 hours and CMS Re-review success rate was 68%.

WHAT DOES THIS MEAN TO YOU?

When evaluating MSP partners, check out their numbers. Find out:

Their success rates for clinical interventions and the average dollars saved because of those interventions;
The number of Medicare conditional payment searches and investigations initiated and their success rates for disputes and appeals, including total dollars saved;
How many Medicare Advantage plan searches and investigations they’ve conducted;
A breakdown of the percentage of CMS MSA approvals, counter-highers and counter-lowers;
Percentage of counter-highers submitted for re-review and their success rate.
How they leverage Section 111 data to improve accuracy with conditional payments and MSAs.

COMPLIANCE BY THE BOOK, CLOSURE BY THE NUMBERS

If the above resonates with you, I encourage you to check out our website. We’ve redesigned the site to better reflect our commitment to MSP compliance solutions, not just services. Throughout the site, you’ll see metrics like those above, as well as many other key performance indicators that we use to measure performance, manage improvements and optimize outcomes. You’ll also see specific case studies that demonstrate the successes achieved with MSAs, conditional payment negotiations, physician follow up and clinical interventions, as well as what our clients have to say about working with Tower.

For questions, or to learn more about how Tower is Measurably Better, please email us at info@towermsa.com or call us directly at 888.331.4941.

Tower MSA

Category: Blog