Category: Blog

Tower Partners: People Behind the Settlements Interview with Kevin Puckett of KP Underwriting

February 16, 2023

Picture of Kevin Puckett for Tower Partners: People Behind the Settlements

Tower MSA Partners is pleased to launch “Tower Partners: People Behind the Settlements.”  This quarterly series will dig into the elements that go into smooth, cost-effective settlements and introduce Tower’s team members and corporate partners who make them possible.

First up is Kevin Puckett, owner and president of KP Underwriting, who is responsible for assigning a rated age on most of the MSAs we write.  As Kevin explains, a rated age is the statistical age of a person due to their medical conditions.  A person’s actual age may be 60, but their comorbidities and other conditions could cause their rated age to be 65.

Why is this important to the MSA?  Because an MSA is calculated over the injured worker’s life expectancy. A higher rated age that reflects a shorter life expectancy reduces future medical costs. This reduction can be significant, sometimes tens or even hundreds of thousands of dollars.

Case in point: a 67-year-old woman with a rechargeable spinal cord stimulator (SCS) would have required two revisions (one every nine years) over her 18-year life expectancy, in addition to other medical costs. The MSA’s initial allocation was $142,410.64. However, the rated age came back at 72, reducing life expectancy from 18 to 14 years.  This allowed Tower to remove one SCS revision along with other medical costs. The revised MSA was $98,586.35, a $43,824.29 reduction to the allocation.

Now, let’s turn to our rated age expert and partner, Kevin Puckett.

Q & A with Kevin Puckett

What is a rated age? 

A rated age is an adjusted age and reduced life expectancy, that is the expected number of years of life remaining at a given age based on an individual’s medical impairments and the impact they have on their body and life expectancy.  The US Health & Human Services National Vital Statistics life expectancy tables set the baseline for life expectancy determinations.

What is your background in providing rated ages?  What qualifies you to provide this service?

I have been the President and Owner of KP Underwriting, LLC, an independent underwriting company since 2004.  KP Underwriting provides rated ages and modified life expectancies for companies that provide structured settlements, Medicare Set-Asides, and medical cost projections. Our services are also used for settlement purposes and to help set reserves. During my 30+ year career in medical underwriting, I worked with multiple life insurance companies, developing and managing underwriting departments before launching KP Underwriting.  I’ve also written underwriting manuals, audited underwriting departments, and provided expert witness testimony on life expectancy in multiple states and for the Department of Justice.  I earned my BBA in Business Administration with a minor in Biology from Eastern Kentucky University, an Associates designation from the Academy of Life Underwriting, and an FLMI (Fellow, Life Management Institute).

Is KP Underwriting approved to provide rated ages for CMS?

Yes, we’ve been approved since 2006. KP Underwriting is the single largest provider of rated ages in the country, having provided several hundred thousand rated ages to the Centers for Medicare and Medicaid Services (CMS).

What documentation do you require to calculate the rated age?

Medical records should contain two primary categories of records as listed below.  Medical records within the past two years are considered current and have more weight in rated age calculations.

  • Current status of the claimed injury includes:
    • Length of time since injury, permanency of the condition, functional status, stability of treatment, nature of the ongoing treatment.
  • Overall medical status of the individual including:
    • All co-morbidities, personal medical history, pharmaceutical use and related conditions.

Medical records older than two years can be utilized, however, the rated age will normally be more conservative as health history and medical impairments can change drastically over a two-year timeframe or longer.

Can you provide examples of diagnoses that will increase the rated age?

Two conditions can impact the rated age and life expectancy: the injury itself and medical impairments.  Good examples of both are as follows:

  • Injuries
    • Spinal Cord Injuries, head injuries, amputations, burns, chemical exposure, and falls are the most significant. The best thing to consider with injuries is how and if it impacts daily functioning.
  • Medical impairments
    • Most major health impairments will impact the rated age, such as diabetes, stroke, coronary artery disease, obesity, smoking, peripheral artery disease, kidney, colon, and liver diseases, HIV/AIDS, post-covid syndrome, and major respiratory disorders, to name a few. This is a very broad category.  One of the things I cannot stress enough is that medical impairments usually have the biggest impact on the rated age.

Do you solely consider the injury-related diagnoses or both the injury and non-injury-related diagnoses?

The injury and residuals and any medical impairments are both considered in processing the rated age.  We try to let our clients know that not only healthy people get injured.  Medical impairments usually have the biggest impact on rated ages.  In some instances, medical impairments can prevent or delay healing from the injury. For example, diabetes can delay healing in cuts or burns, leading to amputation or slower response to treatment.

What is your typical turnaround time to provide a rated age?

KP Underwriting’s turnaround time is usually 2-3 hours, with rush requests completed within an hour.  All cases that come in before 4 pm EST are completed the same day.  All cases after 4 pm are completed first thing the next business day.

What does your rated age report contain?

 The rated age report sent back to our clients is on KP Underwriting letterhead and contains the name, date of birth, gender, current age and current life expectancy, rated age and rated life expectancy, a brief medical summary of the impairments and injuries used in consideration of the rated age, and the table used in our calculations.  These are tailored to meet our clients’ needs.

How long has KP Underwriting been in business?

KP Underwriting has been in business since 2004. Initially, we prepared rated ages mainly for life companies and structured settlements.  We branched out in 2006 to include rated age services for MSAs.

Do you do all the rated age calculations, or do you have a staff that assists you?

KP Underwriting grew quickly to the point that I needed help to do them.  I currently have a staff of 10-from underwriters to processors- who assist in the rated age process.

If you want more information on KP Underwriting, you can visit their website or contact Kevin at kevinp@kpunderwriting.com or (502) 345-8048.  And if you have a question about a specific MSA or the impact of rated ages on MSAs in general, I am happy to speak with you.  Email Daniel.Anders@TowerMSA.com.

Risk & Insurance: Am I Allocating Enough for a Medicare Set-Aside? Take These Pointers from a Pro to Find Out

January 26, 2023

Man in business suit looking confused about Conditional Payments

Tower’s MSP Compliance blog analyzes the nuances of Medicare Set-Asides (MSAs) and other aspects of Medicare Secondary Payer Compliance. It covers topics like re-reviews and the termination of ongoing responsibility for medicals (ORM), along with tweaks to WCMSA Reference Guide. Most of our posts drill down into the fine details that our readers need to know.

Every now and then, though, it’s good to pull back and take a high-level view of MSAs as our Chief Compliance Officer Dan Anders does in this Risk and Insurance article. Keep it handy in case you need to explain MSAs to an injured employee … or a colleague.

Premier Webinar: Zeroing in on $0 MSAs

January 25, 2023

Details for Feb 15 webinar for Medicare Set-Aside (MSA's)

A $0 MSA remains an option in some workers’ compensation case settlements, although strict criteria must be met if CMS approval is necessary.  It is essential then for claims professionals to understand this criteria as steps taken early in claims handling can sometimes be the difference between a $0 and a fully funded MSA at the time of settlement.

Over his two decades in MSP compliance, Tower’s Chief Compliance Officer, Dan Anders, has successfully obtained CMS approval on hundreds of $0 MSAs.  Please join him for a Tower Premier Webinar on Feb. 15 at 2 PM ET.

In addition to $0 MSAs, Dan will also discuss using state statutes and regulations to limit MSA amounts.

The presentation covers the following:

  • Criteria for a CMS-approved $0 MSA
  • Alternative criteria for a Non-Submit $0 MSA
  • A step-by-step guide as to how to work with Tower to obtain a $0 MSA.
  • Use of state statutes and regulations to limit the MSA amount.

A Q&A session will follow the presentation, and you can provide questions you’d like us to cover when you register. Please click the link below and register today!

Please note that there is no CEU credit offered for this webinar.

Register Here

A Claims Professional’s Guide to Common MSP Acronyms and Abbreviations

January 19, 2023

Picture of scrabble tiles that could be put together to create MSP ACRONYMs

People in the MSP compliance business rattle off acronyms and abbreviations, such as AWP, MMSEA, and TPOC like it’s second nature. People immersed in Section 111 reporting and Medicare Set-Asides understand the abbreviations, but most people listening to us do not. So, here’s a quick cheat-sheet (or handy guide) to frequently used acronyms and their meanings:

Common MSP Acronyms and Abbreviations

AWP – Average wholesale price:  The AWP is a Red Book pricing reference for prescription drugs. The lowest AWP is used to calculate Medicare Part D drugs in a Workers’ Compensation Medicare Set-Aside (WCMSA).

BCRC – Benefits Coordination & Recovery Center: This contractor to the Centers for Medicare and Medicaid Services consolidates the activities that support the collection, management, and reporting of other primary insurance coverage for Medicare beneficiaries.  In short, it manages the MMSEA Section 111 reporting program and pursues conditional payment recovery when the claimant Medicare beneficiary is the debtor.

CMS – Centers for Medicare and Medicaid Services:  The federal government agency oversees the Medicare program.  CMS’s Division of MSP Program Operations directly manages CMS’s Medicare Secondary Payer (MSP) enforcement programs.

COB – Coordination of Benefits:  The coordination of benefits (COB) program aims to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken payment of Medicare benefits.

CRC – Commercial Repayment Center: This CMS contractor pursues conditional payment recovery when the self-insured entity or the insurer is the identified debtor.

CWF – Common Working File: CMS uses this tool to maintain national Medicare records for individual beneficiaries enrolled in the Medicare program.  For example, a funded CMS-approved workers’ compensation Medicare Set-Aside (WCMSA) will trigger a marker in the CWF, so Medicare will not pay for care covered by the WCMSA.

LMSA – Liability Medicare Set-Aside: General term for an MSA in a liability case settlement.

MBI – Medicare Beneficiary Identifier:  The Medicare Beneficiary Identifier (MBI) is the identification number replaced SSN-based health insurance claim numbers (HICNs) on all Medicare transactions, such as Medicare cards, billing, claim submissions and appeals.

MIR – Mandatory Insurer Reporting:  Another term for MMSEA Section 111 reporting.

MMSEA – Medicare, Medicaid, SCHIP Extension Act of 2007: Section 111 of this act added mandatory reporting requirements regarding Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards, or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation, collectively referred to as Non-Group Health Plan (NGHP) or NGHP insurance.

MSA – Medicare Set-Aside: An account used to pay for injury-related and Medicare-covered medical services and prescription medications. It is a portion of a settlement that is reserved or “set-aside” for this purpose.

MSP – Medicare Secondary Payer: This is the term generally used when the Medicare program does not have primary payment responsibility, that is when another entity, such as workers’ compensation or liability insurance or a group health plan, is responsible for paying before Medicare.

MSPRP – Medicare Secondary Payer Recovery Portal: A web-based tool designed to assist in the resolution of liability insurance, no-fault insurance, and workers’ compensation Medicare recovery cases.

NGHP – Non-Group Health Plan: Typically used in reference to Section 111 reporting, NGHP includes liability insurance (including self-insurance), no-fault insurance, and workers’ compensation.

ORM – Ongoing Responsibility for Medicals:  This refers to the Responsible Reporting Entity (RRE) paying for the injured party/Medicare beneficiary’s ongoing medical treatment associated with the claim.

RO – Regional Office:  A CMS RO is assigned to each WCMSA case (based on the claimant’s state of residence); that RO makes the final determination of the appropriate funding level for the WCMSA.

RRE: Responsible Reporting Entity: The applicable plan, namely the NGHP, responsible for Section 111 reporting to CMS.

SSDI – Social Security Disability Insurance: Pays monthly benefits to workers who can no longer work due to a significant illness or impairment that is expected to last at least a year or result in death within a year.

SSN – Social Security Number: A numerical identifier assigned to U.S. citizens and other residents to track income and determine benefits.

TPOC – Total Payment Obligation to the Claimant: For Section 111 reporting purposes, CMS uses the term TPOC to refer to 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 in addition to/apart from ORM.

WCMSA – Workers’ Compensation Medicare Set-Aside: This is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease.

WCMSAP – Workers’ Compensation Medicare Set-Aside Portal: The WCMSAP may be used to submit and view WCMSA proposals, to communicate about the review approval process, and to submit re-review requests. Users can also view the status and balance of an established WCMSA and submit annual attestations and detailed transaction records.

WCRC – Workers Compensation Review Contractor: This CMS contractor reviews all submitted WCMSAs and advises the CMS Regional Office whether the proposed WCMSA is sufficient, or a higher or lower amount is recommended.

CMS to Provide RREs with Response File on ORM Record Changes

January 11, 2023

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

Starting July 2023, Responsible Reporting Entities (RREs) can access updates/changes that another source has made to their claims for Ongoing Responsibility for Medicals (ORM).  The Centers for Medicare and Medicaid Services (CMS) announced this in an update to its MMSEA Section 111 NGHP User Guide, Version 7.0.

It may surprise insurers and self-insurers that the ORM data they report through Section 111 reporting can be modified by the Benefits Coordination and Recovery Center (BCRC), which coordinates benefits on behalf of CMS. For example, suppose a claimant contacts the BCRC and advises that they are being denied medical care due to an open ORM (ORM indicates the RRE accepts the claim). In that case, the BCRC may update the ORM record to indicate that medical has been terminated (especially if the claimant indicates the case has been settled).

The RRE needs to be notified of this action to correct its reporting or to advise the BCRC that this was an erroneous change to the record.

Presently, and in our experience, the BCRC typically issues a letter to the RRE advising of the change it made to the ORM status.  Starting this summer, RREs can also access these changes through Section 111 reporting. The revised user guide states:

Effective July 2023, RREs will be able to opt in via the Section 111 secure website to receive a monthly NGHP Unsolicited Response File. This will provide critical information about updates to ORM records originally submitted in the last 12 months and allow RREs to either update their internal data or contact the Benefits Coordination & Recovery Center (BCRC) for a correction.

This report will provide the source of the record modification and the reason for it. This should eliminate confusion when the BCRC changes ORM reporting data.

Other Updates to Section 111 User Guide

CMS included these other updates in Version 7.0 of the user guide:

  • Sections 6.4.2, 6.4.3 and 6.4.4. of Chapter III: Policy Guidance indicated CMS would maintain the $750 reporting threshold for physical trauma-based liability insurance settlements and the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals.
  • In Chapter IV: Technical Information besides the aforementioned ability to, as of July 2023, obtain an NGHP Unsolicited Response File, CMS put in place the following changes:
  • Information on recovery agents was clarified to emphasize that such agents need written authorizations to pursue any post-demand actions (Section 6.3.1).
  • Recovery agents may now view the Open Debt Report on the Medicare Secondary Payer Recovery Portal (MSPRP), if the agent has an active MSPRP account with a TIN matching one submitted on the RRE’s TIN Reference File (Section 6.3.1.2).
  • ORM Termination Date field number 79 was corrected for the Event Table (Section 6.9.1).

As Tower is a recovery agent for many of our clients, the ability to download a copy of the Open Debt Report will be helpful in monitoring CMS’s ongoing recovery actions.

  • Finally, CMS updated Chapter V: Appendices as follows:
  • The CP13 soft edit policy limit amount has decreased from $1000 to $500 (Appendix F).
  • For the TIN Reference File, the Go Paperless Indicator is no longer required when submitting the Recovery Agent TIN (Field 25) (Appendix G).

If you have any questions on these updates, don’t hesitate to contact Tower’s Chief Compliance Officer, Dan Anders, at Daniel.anders@towermsa.com or 888.331.4941.

 

Top 5 MSP Stories of 2022 & What to Watch for in 2023

January 4, 2023

pictures of 2022 & 2023 to showing size difference in 22 & 23 MSP

As we launch into 2023, here’s a look back at the top five Medicare Secondary Payer (MSP) compliance stories of 2022 and what to watch for this year.

Addition of Non-Submit MSA Policy to CMS WCMSA Reference Guide

2022 certainly got off with a bang when CMS added Section 4.3 to the CMS Workers’ Compensation MSA Reference Guide.  Entitled “The Use of Non-CMS-Approved Products to Address Future Medical Care,” the policy, which was later amended (See CMS Clarifies Policy on Non-Submit MSAs in Updated Reference Guide), provides as follows:

  • A non-submit MSA represents a potential cost shift to Medicare.
  • At its sole discretion, CMS may deny payment for injury-related medical up to the total settlement amount less procurement costs and paid conditional payments.
  • If the non-submit MSA exhausts, it must be demonstrated that the MSA was sufficiently allocated at the time of settlement and the funds were spent properly.
  • Shall apply to all notifications of settlement that include the use of a non-CMS-approved product received on, or after January 11, 2022
  • It does not apply to under-threshold MSAs (settlements that do not meet the CMS WCMSA review criteria).

Questions remain.  To what extent will CMS issue denials where a non-submit MSA is used? How will this process work when a non-submit MSA exhausts? What steps will CMS take to determine the sufficiency of the MSA when the claim is settled? And what evidence will CMS require to prove the MSA funds were spent correctly?

Ametros Study Confirms Post-Settlement Medicare Denials Do Occur

The question of whether CMS denies payment for injury-related care was answered, at least for CMS-approved MSAs, in an extensive study Ametros published in January 2022.  This first-of-its-kind study examined a random sample of five percent of the Medicare beneficiary population over a three-year period.  They estimated that the following number of claims were denied because WCMSA funds were responsible for their payment.

  • 35,980 in 2018
  • 36,060 in 2019
  • 30,720 in 2020

The report’s key conclusion is “Medicare is systematically denying MSA recipients’ claims, and with steady frequency.”  You can download the free report “A Study of CMS Policy on Treatment Denials for Injured Workers with a Medicare Set Aside from ametros.com/medicaredenials. 

CMS Releases Key Metrics on WCMSA Review Program

It was not only Ametros that published data related to the MSP program in 2022.  For the first time, CMS released data on its WCMSA review program.

CMS shared statistics for the three-year period of 2020 through 2022.  The data compared proposed MSA amounts with the CMS-recommended amounts (what we typically call the “approved” MSA amounts).

Key takeaways from a review of the three years of data:

  • MSA reviews are down, a 17% decline over three years.
  • Review methodologies remain consistent.
  • The average recommended MSA remains consistently between $80K-$85K.
  • A billion dollars in recommended MSAs every year.

Please see For the First Time, CMS Release Key Metrics on WCMSA Review Program for more takeaways and a link to the data.

CMS Withdraws Proposed Rule on Future Medicals in Liability

In a surprise move, CMS withdrew its proposed rule on future medicals in liability settlements from review by the White House Office of Information and Regulatory Affairs (OIRA review and approval are required before a proposed rule is published). It was anticipated that CMS would release the proposed rule in 2022 for comment, but we did not even get to that step in the regulatory process.

The future of formal CMS guidance for liability settlements remains unknown.  While CMS can resubmit a proposed rule for release, we do not know if it will do so or the timeline if it intends to do so.

Notably, in its recently released solicitation for its next five-year Workers’ Compensation Review Contractor (WCRC) contract, CMS included an option for liability MSAs reviews starting in April 2024.  However, while CMS anticipates 19,200 WC MSA submissions per year, the solicitation indicates an expectation of 1,000 per year in LMSAs (with an option to increase to an additional 3,000 per year).  In short, even were CMS to put some LMSA review process in place it seems they contemplate a high dollar or some other type of threshold to reviews given the lower number expected.

In response to CMS’s lack of guidance, Tower released an updated version of its guidance document, Navigating Through the Fog: Medicare Future Medicals & Liability Settlements.

First Anniversary of PAID Act Implementation

On 12/11/2021, payers, gained access to the past three years of Medicare beneficiary enrollment status in Medicare Part C (known as Medicare Advantage) plans and Part D (prescription drug) plans through the Section 111 reporting data. Previously, workers’ compensation payers were required to reimburse these plans for conditional payments but did not know which plans the Medicare beneficiary used.

The PAID Act did not introduce new requirements for resolving debts with Part C and D plans. However, it does allow payers, in some cases, to more easily identify and contact these plans.  Observations one year out:

  • In terms of the technical aspects of the transmission of PAID Act data, there have been minimal problems.
  • Not all RREs have chosen to accept the PAID Act data into their claims systems (Tower created a dashboard allowing our reporting clients to access PAID Act data without having to ingest it into their claims system).
  • While the enrollment information for Part C and D plans is accurate, the same can’t be said for the contact information. (Note, CMS issued a memo in April 2022 to Part C and D plans asking them to provide contact information which can receive inquiries from Non-Group Health Plans in compliance with the PAID Act.)
  • There has been an increase in Tower clients’ pre-settlement requests to contact Part C and D plans to inquire about reimbursement claims.

What to Watch for in 2023

Section 111 Penalties:  2/18/2023 is the due date for CMS to issue final regulations on criteria for imposing Section 111 penalties for improper mandatory reporting.  We expect issuance before this date with final regulations becoming effective this year.

MSA Review Contractor:  Capitol Bridge, the Workers’ Compensation Review Contractor (WCRC), is in the last year of its five-year contract to review MSAs for CMS.  On 1/4/2023 CMS published the solicitation for a new five-year contract set to begin on 4/1/2023.

The new contract contemplates 19,200 WC MSA submissions with no increase over the contract period.  What to watch for here is whether CMS keeps Capitol Bridge or brings in a new contractor.

Release of More MSP Metrics:  As noted above, we were pleased to see CMS release critical metrics around the MSA review program.  We hope this becomes an annual report and expands with more data around MSA administration post-settlement and conditional payment recovery.

Best wishes from your friends at Tower for a healthy, happy and prosperous new year!

Happy Holidays From Your Friends at Tower MSA Partners

December 21, 2022

Happy Holidays sign

We’ve had an exciting year of growth at Tower MSA Partners in 2022 and would like to extend our appreciation to you, our valued partners, who have supported us.  Whether this is your first year as a Tower client, or one who has been with us for many years, Tower’s success results from your loyalty.

Our team works diligently each and every day to earn your trust by providing a service level unmatched in the MSP industry.  And we can do that only through the expertise, knowledge, professionalism and commitment of our amazing staff, also unmatched in our industry.  Together with our team, we hope we have met and exceeded your service expectations throughout the past year.  

We extend our warmest wishes to you and yours. A Merry Christmas and Happy Holidays from your friends at Tower MSA Partners. 

 

Tower Releases White Paper on Future Medicals in Liability Settlements

December 13, 2022

woman sitting in a dr waiting room to discuss her liability case

This past October, the Centers for Medicare and Medicaid Services (CMS) withdrew its proposed rule on future medicals in liability settlements from review by the White House Office of Information and Regulatory Affairs (OIRA). (See CMS Withdraws Proposed Rule on Future Medicals in Liability Settlements).

Right now, we don’t know if a proposed rule around Liability Medicare Set-Asides (LMSAs) will be reworked and resubmitted to OIRA for consideration soon or whether CMS is closing out regulations around liability settlements and future medicals for the foreseeable future.

Given the lack of guidance from CMS, we thought this was an opportune time to update our white paper, Navigating through the Fog: Medicare, Future Medicals & Liability Settlements.  Authored by Tower’s Chief Compliance Officer Dan Anders, the paper explores CMS authority to regulate future medicals and provides guidance to the liability practitioner as to how to address future medicals at the time of settlement.

 

Post-Settlement Care, Cost and Compliance Through Professional Administration

December 6, 2022

Picture of Medicare billing statement for Section 111 WCMSA reporting

While workers’ comp payers invest considerable resources to manage and settle claims, they don’t always prepare Medicare-eligible injured workers for life after settlement. These patients have usually been in the workers’ comp system for several years. And the system has paid for their injury’s treatment and medication, and in some cases, coordinated their care.

When their claim closes, all that comes to an end. Injured workers are on their own to navigate the healthcare system and handle the bills. They need to pay for doctors’ visits and medication from their Medicare Set-Asides (MSAs). They also need to make sure Medicare doesn’t have to pay for their injury-related care. Post-settlement compliance responsibilities can be overwhelming.

Tower’s recent Premier Webinar: Care, Cost & Compliance Through Professional Administration featured Nicole Chappelle who has nearly 30 years’ experience in all aspects of claims management — before and after settlement. Now Vice President of Settlement Solutions for Tower’s partner Ametros, Nicole joined our Chief Compliance Officer Dan Anders for what could be our liveliest webinar yet.

Here are some takeaways:

  • Injured workers who are also Medicare beneficiaries can self-administer their MSA or use professional administration.
  • The Centers for Medicare and Medicaid Services (CMS) highly recommends professional administration for beneficiaries who take opioids and other frequently abused controlled substances.
  • Professional administration is available for MSAs that are CMS-approved and for those that are not submitted for CMS approval.
  • Payers typically cover Ametros’ one-time professional administration fee of $1,000.

Although CMS allows beneficiaries to self-administer an MSA, it strongly recommends they consider professional administration.  So do we.

First, MSA funds can only be used to pay for Medicare-covered medical treatment and prescription drugs related to the claim. Learning what Medicare does and doesn’t cover is challenging at best. It’s even more confusing for an injured worker whose workers’ comp program paid for items that Medicare does not cover, such as a sophisticated power wheelchair, home healthcare, and off-label use of certain medications. Will the typical, older injured worker understand this?

Additionally, MSA funds must be kept in an interest-bearing checking or savings account and used only for the aforementioned Medicare-covered care related to the claim.  Even the interest needs to be used for this purpose.

The administrator has to maintain itemized medical and pharmacy receipts, bank statements, and other records for each transaction from the MSA account. An attestation of these expenditures needs to be submitted to the Benefits Coordination & Recovery Center (BCRC) every year.

If the MSA is funded with an annuity and funds run out in any given year, the administrator must report the temporary exhaustion of funds to the BCRC. Should funds be permanently exhausted, the administrator needs to send the BCRC a final attestation letter confirming the situation.

If MSA funds remain when the beneficiary dies, the executor or administrator is to notify the BCRC and pay for outstanding (related) medical bills from the fund.  But would an executor know to do this?

Some things are best left to professionals.

If you’d like to see the whole webinar, please contact Dan Anders at daniel.anders@towermsa.com for the link and slides. He’s happy to connect you with Nicole Chappelle, too.  And, as always, if you have any questions about MSAs, post-settlement compliance, or other Medicare Secondary compliance issues, get in touch with Dan.

Related posts:

Study Shows Post-Settlement Medicare Treatment Denials Do Occur

Build a Better Tower: Partnerships Speed Settlements of Workers’ Comp Claims with Medicare Set-Asides (towermsa.com)

CMS Announces Upcoming Section 111 Webinar / WCMSA Reference Guide Update Released

November 15, 2022

Red Medicare button on a keyboard to illustrate Medicare conditional payment.

The Centers for Medicare and Medicaid Services (CMS) recently published a Section 111 reporting webinar notice and an update to its CMS WCMSA Reference Guide.

CMS Section 111 Reporting Webinar

CMS will hold a Section 111 NGHP Webinar on December 6, 2022, at 1:00 PM ET.  The notice says:

CMS will be hosting a Section 111 NGHP webinar. The format will be opening remarks by CMS, a presentation that will include NGHP reporting best practices and reminders followed by a question and answer session. For questions regarding Section 111 reporting, prior to the webinar, please utilize the Section 111 Resource Mailbox PL110- 173SEC111-comments@cms.hhs.gov.

The webinar notice can be found here.  We encourage anyone involved in the management of Section 111 reporting to tune into it.  Please note that there is no pre-registration; instead, the link and call-in phone numbers are on the notice.  You just log in shortly before the webinar’s start time.

WCMSA Reference Guide Update

The update to CMS’s WCMSA Reference Guide, Version 3.8 provides for changes to the re-review criteria. (Because CMS does not have a formal appeals process after an MSA determination, it allows what are called re-review submissions).  Currently, CMS allows for re-reviews for mathematical errors and missing documentation.  It has now added a section for submission errors which provides:

Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual. Note: This submission option is only available for approvals from September 1, 2022 forward.

  •  Examples include, but may not be limited to: medical records with incorrect patient identifying information or rated ages where the rated-age assessor provided incorrect information in the rated-age document.

Rather than applying to submitter errors, this addition to the re-review policy appears to account for errors in the documentation that was provided to the submitter, such as a rated age or medical records.

Tower conducts a thorough review of all relevant documentation when the MSA is prepared and submitted.  Consequently, documentation errors are identified and corrected before MSA submission.  As such, we expect to make minimal use of the Submission Error Re-Review.

CMS also added a new section entitled Re-Review Limitations:

16.2 Re-Review Limitations

 Note: The following re-review limitations are only available for approvals from September 1, 2022 forward.

 Re-review shall be limited to no more than one request by type.

 Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error.

 Re-review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.

It appears that the long-time policy of unlimited re-reviews has come to an end.  We understand CMS’s statement that a re-review “shall be limited to no more than one request by type” to mean one re-review is allowed for a mathematical error, one for missing documentation, and one for a submission error.

CMS’s intention for stating that a “disagreement surrounding the inclusion or exclusion of specific treatment or medications does not meet the definition of a mathematical error” is not clear.  While perhaps not a math error, when medical records from a treating physician clearly say surgery is no longer recommended or medication has been discontinued but CMS includes such treatment or medication in the MSA, we submit it as an error.

Tower has submitted numerous re-review requests to remove or modify treatment or medication from the MSA based on treating physician statements in the medical records.  Tower has a 68% success rate with re-reviews when CMS previously issued an MSA counter-higher, proof that these are reasonable requests. We hope the addition of Section 16.1 does not signal CMS’s intention to reject these reasonable re-review requests.

If you have any questions, please do not hesitate to contact Dan Anders, Tower’s Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.