Medicare Set-Asides Archives

Why Isn’t the Claim Settling? The MSP Issues Beyond the MSA that Can Derail a Settlement

September 2, 2026

By Louis Porrazzo, Esq., Chief Legal Officer, Tower MSA Partners and Claimify

For the past 25 years, the Medicare Set-Aside Arrangement (MSA) has been treated as the crown jewel of Medicare Secondary Payer (MSP) compliance. And rightfully so! An inappropriately high-dollar MSA can derail a settlement, an improperly prepared MSA may not survive review by the Centers for Medicare and Medicaid Services (CMS), and an insufficiently funded MSA can leave the injured worker in a Medicare quagmire.

During that same timeframe, the industry has become reasonably proficient at ensuring that an MSA is appropriately calculated, that an MSA submitted to Medicare has a strong likelihood of approval near the submitted amount, and that the MSA is properly funded and administered.

And yet, parties still routinely encounter MSP-related issues that prevent or delay settlement. Even when an MSA has been prepared, submitted, approved or indemnified, and funding and administration have been arranged, the parties still carry ongoing MSP obligations that must be met.

Improper Section111 reporting, failure to properly address conditional payments, and inconsistent claim information can derail a settlement at the eleventh hour. Individually, each of these issues can be managed without much difficulty. The challenge is that they are rarely identified early enough to be handled as routine compliance work.

MSP compliance must be fully integrated into all aspects of claims handling. If the first meaningful discussion about Medicare occurs during settlement negotiations, the parties are already at a disadvantage.

Here are five MSP-related issues to address before the settlement becomes derailed:

1. Section111 Data is Inconsistent

The handling adjuster is responsible for maintaining accurate claim information, ensuring appropriate ICD codes are used, and paying only for treatment and services for which the payer is responsible. Defense counsel may be litigating the accepted body parts, correct date of injury, causal relationship, and other aspects of the claim. And some organizations have entire departments or outside vendors dedicated to Medicare reporting. Their efforts should be aligned. Too often, they are not.

Dates of injury, ICD codes, ORM (Ongoing Responsibility for Medicals) status and termination dates, TPOC (Total Payment Obligation to the Claimant) information, and other reporting data should accurately reflect the claim being settled. This has become even more important as CMS has expanded Section111 reporting requirements to include WCMSA information and increased its focus on reporting timeliness and accuracy. CMS began quarterly Section 111 reporting audits in the first quarter of 2026, sampling accepted records and assessing civil money penalties where ORM assumption or TPOC was reported outside the required timeframe. Reporting data that was merely untidy a year ago now carries a direct financial consequence.

Inconsistent data can create significant problems. Multiple Medicare records may be established or associated with a claim, potentially triggering unnecessary recovery activity. Inaccurate information can complicate settlement documentation and reporting. And improper coding may cause confusion regarding which injuries and medical treatment are actually related to the workers’ compensation claim.

Before the parties settle, they should ensure that what is reported under Section111 matches the claim that is about to close.

2. Ambiguity Surrounding ORM

When an accepted workers’ compensation claim is settled and the payer’s responsibility for medical treatment ends, ORM generally needs to be terminated, and applicable TPOC information reported under Section 111. The key question is whether ORM should have been accepted in the first place.

When did responsibility for medical treatment begin?
Was it ever accepted or denied?
Does it remain open?
Is there a legitimate basis for terminating ORM?
If so, when should the termination be reported?

These decisions should not be made automatically simply because a claim is established at the front end or the claim is settling on the back end. Inaccurately accepting ORM can create problems beyond Section111 reporting itself, including unnecessary conditional payment recovery efforts and confusion regarding accepted injuries.

Settlement is a good time to review Section111 and ORM activities, but it should not be the first time these questions are asked.

3. Forgotten Conditional Payments

Far too often, conditional payments are an afterthought. The industry has become very good at knowing how to prepare an MSA, how to obtain approval when submission is appropriate, how to fund it, and how to administer it. But conditional payments still go unaddressed until the last minute.

CMS may seek reimbursement for payments it believes are related to the workers’ compensation claim, including charges that the payer believes are unrelated or otherwise not their responsibility. Failing to investigate and address those payments early can lead to unnecessary reimbursement demands and delays in bringing the claim to final resolution.

Organizations can save money by addressing conditional payments in a timely fashion. Just as importantly, accurate Section 111 reporting and proper conditional payment resolution can reduce confusion over responsibility for medical treatment. These issues can usually be resolved, but resolution takes time. A conditional payment issue discovered months before settlement is a compliance task. The same issue discovered days before settlement can become a settlement problem.

4. When Everyone Owns MSP Compliance, No One Does

It is important for all parties to align on MSP-related activities and expectations. The adjuster and defense attorney should be in lockstep when it comes to handling the MSA, conditional payments or Section 111 questions. Both parties should have a working relationship with the MSP vendor of choice. And the claimant’s counsel should understand their obligations in denied workers’ compensation cases.

MSP compliance involves multiple interconnected obligations, and treating each one as an independent transaction creates opportunities for things to be missed. Each party should know which tasks belong to them. Before settlement discussions begin, parties should understand:

What is accepted and what remains denied or disputed?
Is the claimant Medicare eligible or reasonably expected to become Medicare eligible?
Is §111 reporting accurate, including ORM status?
Who is responsible for resolving conditional payments?
What is the strategy for MSA preparation, funding, and administration?
If an MSA is appropriate, will the parties pursue CMS submission or utilize another risk-management approach such as indemnification?

While different people will be handling different aspects of MSP compliance, it is important to have one person or department leading the charge and bringing all parties together to ensure MSP compliance.

5. MSP Protocol vs. “Getting an MSA”

Every entity should have a defined MSP protocol in place to ensure compliance. The mindset should shift from “getting an MSA” to “complete MSP compliance.” Any settlement strategy should include Medicare from the beginning.

Is there a discrepancy in treatment? Address it during claims handling so it doesn’t become an issue at settlement.

Is the case denied? Do not automatically assume that ORM should be reported. Analyze whether responsibility for medical treatment has actually been accepted and report accordingly.

Is the claimant treating body parts unrelated to the injury? Do not pay for that treatment. Those payments can inflate the MSA and complicate CMS approval.

By the time everyone has agreed on a settlement number, expectations have been created and momentum matters. An unexpected Medicare issue at that stage does more than increase costs. It can destroy that momentum and prevent the settlement from closing.

Final Thoughts

MSP compliance should be built into the overall claims strategy from the beginning. Section 111 reporting, conditional payments, future medical exposure, and settlement all intersect, and problems in one area can quickly affect another. A well-defined MSP protocol gives the parties an opportunity to identify and resolve those issues while there is still time to keep the claim moving toward settlement.

The best time to discover a Medicare problem is when there is still time to do something about it. When the claimant wants to settle, counsel agrees to settlement terms, the adjuster has authority, and the MSA is complete, the last thing anyone wants to hear is “We still have a Medicare issue.” A well-built MSP Protocol is what keeps that sentence out of the room.

On Wednesday, September 16, at 2:00 p.m. ET, join Tower’s Chief Legal Officer, Lou Porrazzo, and Tower’s Chief Compliance Officer, Dan Anders, for a practical discussion of five MSP-related issues that commonly delay workers’ compensation settlements and what claims professionals can do to identify and resolve them earlier.

Frequently Asked Questions About MSP Issues That Delay Settlement

Why do workers’ compensation settlements get delayed by Medicare issues?

Most delays come from issues outside the Medicare Set-Aside itself. Inconsistent Section 111 data, unresolved conditional payments, and unclear ORM status surface late in negotiations, when the parties have already agreed on a number and have no time to fix them.

What Section 111 data should be verified before settlement?

Confirm that the date of injury, ICD codes, ORM status and termination date, and TPOC information all match the claim being settled. Since April 2025, WCMSA amounts must also be reported. Mismatched data can trigger duplicate Medicare records and unnecessary recovery activity.

When should ORM be terminated on a workers’ compensation claim?

ORM generally terminates when the payer’s responsibility for medical treatment ends, which usually coincides with settlement. The more important question is whether ORM should have been accepted in the first place, because accepting it in error creates conditional payment exposure that did not need to exist.

Who is responsible for resolving conditional payments in a settlement?

Responsibility should be assigned explicitly before settlement discussions begin, typically to the adjuster, defense counsel, or the MSP vendor. When no one owns it, conditional payments surface days before closing, at which point they become a settlement problem rather than a compliance task.

Does an approved MSA mean the claim is MSP compliant?

No. An approved and funded MSA addresses future medical exposure only. Section 111 reporting accuracy, ORM status, and conditional payment resolution are separate obligations that continue independently and can hold up a settlement on their own.

Louis Porrazzo, Esq. serves as Chief Legal Officer for Tower MSA Partners. A recognized authority on Medicare Secondary Payer (MSP) compliance, Lou is a frequent national speaker and author known for translating complex Medicare compliance issues into practical strategies for claims professionals, attorneys, insurers, and self-insured organizations. He is licensed to practice law in the Commonwealth of Massachusetts and brings extensive experience in MSP compliance, workers’ compensation, and general liability defense. Outside of his professional work, Lou chairs the Kids’ Chance of Massachusetts Fundraising Committee and is a CrossFit Level 2 Certified Trainer. He can be reached at Louis.Porrazzo@TowerMSA.com.

Amended Review Strategy Drops MSA by $101K

July 20, 2026

Tower MSA Partners amended review case study showing $101,312 in Medicare Set Aside savings

In Tower MSA Partners’ last post, How Tower Reduced Conditional Payments to $0, we explained how Tower reduced Medicare conditional payments to zero through detailed review and accurate documentation. This month, we focus on a case where an amended review dramatically changed the outcome of an already CMS-approved MSA. A payer requested help after receiving an unexpectedly high counter-higher from CMS. Through an amended review supported by updated medical records and clinical oversight, Tower corrected outdated projections and reduced the MSA by $101,312. This case shows how persistence and accuracy create better settlement outcomes.

Identifying the Problem

After an MSA had been submitted and approved by CMS, new medical records revealed important changes in the claimant’s treatment plan. Several medications had been discontinued, therapy frequency had decreased, and previously projected diagnostic testing was no longer recommended. As a result, the approved allocation no longer reflected the claimant’s current treatment needs and overstated projected future medical costs.

The allocation no longer aligned with the claimant’s current medical condition or ongoing treatment plan. Moving forward with settlement based on outdated projections would have resulted in funding medical expenses that were no longer supported by the available clinical evidence. The payer needed an amended review to ensure the MSA accurately reflected current medical.

Turning New Medical Evidence Into $101K in Savings

Tower MSA Partners conducted a comprehensive amended review to evaluate the newly available medical information and determine its impact on future medical cost projections.

The clinical team analyzed updated medical records, treatment histories, prescription information, and provider recommendations. During the review, several medications included in the original allocation were confirmed as discontinued and no longer medically necessary. Therapy projections were adjusted to reflect the claimant’s current treatment frequency, and future diagnostic testing recommendations were updated based on the most recent provider documentation.

Using this information, Tower prepared an Amended Review Medicare Set Aside allocation supported by detailed clinical rationale and updated medical evidence. The amended submission clearly demonstrated why the original projections no longer reflected the claimant’s current treatment needs and how the revised allocation more accurately represented future medical exposure.

CMS reviewed the amended Medicare Set Aside submission and accepted the updated allocation, resulting in a reduction of $101,312.

Outcome

MSA Reduction: $101,312
Strategy: Amended Review
Key Findings: Discontinued medications, reduced therapy frequency, and updated diagnostic recommendations
CMS Result: Revised allocation accepted
Impact: More accurate funding and lower settlement costs

Collaboration and Communication

Successful amended reviews require more than updated medical records. They also depend on clear communication among stakeholders involved in the settlement process.

Tower MSA Partners worked closely with the claims professional to review the updated treatment information and ensure the rationale behind each amendment was thoroughly documented. When necessary, providers and defense counsel were consulted to verify treatment changes and eliminate potential discrepancies before resubmission.

This collaborative approach helped streamline the review process and provided CMS with a well-supported allocation backed by current medical evidence. Because the documentation was complete and clearly explained, CMS accepted the revised allocation without requesting additional information.

Why Amended Reviews Matter

Workers’ compensation claims are dynamic. Treatment plans change, medications are discontinued, and providers adjust recommendations based on a claimant’s progress. When those changes occur after an MSA has been prepared or submitted, failing to update the allocation can result in unnecessary funding and inflated settlement costs.

Amended reviews help ensure that Medicare Set Aside allocations remain accurate, defensible, and aligned with current medical evidence. By incorporating updated treatment information before settlement, payers can avoid overfunding future medical expenses while maintaining compliance with CMS requirements.

The amended review identified treatment projections that no longer reflected the claimant’s current medical status. Without the review, the payer would have funded more than $101,000 in projected medical costs that were no longer supported by the treatment record.

Key Takeaways

Amended reviews help ensure Medicare Set Aside allocations reflect current medical necessity.
Updated medical records can reveal opportunities to reduce future medical cost projections.
Discontinued medications and changes in treatment frequency can have a significant impact on MSA allocations.
CMS accepts amended submissions when the changes are supported by credible medical evidence and documentation.
Proactive clinical oversight helped reduce this allocation by $101,312 while maintaining compliance and settlement readiness.

Frequently Asked Questions About Amended Reviews

What is an amended review?

An amended review updates a previously CMS-approved MSA allocation when new medical information becomes available that affects future medical cost projections.

Why are amended reviews necessary?

Claims evolve over time. Updated medical records may reveal discontinued medications, reduced treatment frequency, or changes in provider recommendations that should be reflected in the allocation.

How does an amended review create savings?

An amended review corrects outdated projections and aligns the allocation with current medical necessity. This can reduce unnecessary funding while maintaining compliance with CMS guidelines.

Can an MSA be changed after it has been approved by CMS?

Yes. If significant medical updates occur after submission, an amended review may be appropriate. Updated medical records, physician recommendations, and treatment changes can justify a revised Medicare Set Aside allocation.

CMS Section 111 Update: Key Changes to ORM Termination and TPOC Reporting

May 13, 2026

The Centers for Medicare and Medicaid Services (CMS) has released an update to the Section 111 NGHP User Guide (Version 8.4), introducing important clarifications related to:

Ongoing Responsibility for Medicals (ORM)
Total Payment Obligation to Claimant (TPOC) reporting
Wrongful death claims
Medicare Set-Aside (MSA) reporting in multi-defendant cases.

While many of these updates reinforce existing practices, several changes carry meaningful compliance implications for Responsible Reporting Entities (RREs).

Expanded Guidance on ORM Termination

CMS updated Chapter III, Section 6.3.2 of the Policy User Guide to clarify acceptable circumstances for terminating ORM.

The revised language states:

“Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits, or any other reason that is not prohibited by the terms of the insurance contract or applicable state or federal law.”

CMS also added:

“Note: An insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.”

What This Means

This update introduces helpful flexibility, but it does not create new substantive grounds for terminating ORM. Nonetheless, RREs may feel more comfortable with terminating ORM based on the following:

Claim denials
Independent Medical Examination (IME) results
Maximum Medical Improvement (MMI) determinations
Claimant non-compliance (e.g., refusal of treatment or IME)

In short, CMS has clarified when termination may be recognized, not expanded the legal basis for termination.

Clarification of TPOC Date in Workers’ Compensation Settlements

CMS also added a helpful example in Section 6.4 of the Policy Guide regarding the proper TPOC date to use when commission approval of a workers’ compensation case is required:

“Example: The parties to a workers’ compensation case execute an agreement regarding the claim on 01/20/2026. The state requires the workers’ compensation commission to approve the final settlement details and said approval occurs on 02/05/2026.”

According to CMS, the TPOC date is February 5, 2026, because it was the later of:

The date the agreement was fully executed
The date the court or commission approved the agreement.

What This Means

For many workers’ compensation settlements, this confirms what has already been standard industry practice: the commission approval date will be the TPOC date.

Updated Approach to Wrongful Death Claims

CMS also modified the language in Section 6.5.1.4 related to wrongful death claims.

Previously, CMS stated that wrongful death settlements were not reportable if they:

Did not claim or release medicals, and
Did not have the effect of releasing medicals

The revised language now emphasizes Medicare recovery rights and documentation.

“Note: In order for the wrongful death theory of liability to preclude Medicare from recovering from a settlement, judgment, award, or other payment, complete documentation must be provided that shows what was claimed and released or had the effect of being released. Additionally, a citation to the appropriate state statute or case law that precludes recovery from a wrongful death settlement should be included with any such dispute or appeal.

The prior language was:

Settlements, judgments, awards, or other payments entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported because Medicare would have no recovery claim against such a payment.

What This Means

It is unclear why CMS modified the language in this section, which shifts the focus from the release of medicals to recovery; however, the underlying requirements remain: a settlement is not reportable unless medicals are claimed and released as part of that settlement. This includes a wrongful death settlement.

TPOC Reporting in Multi-Defendant Cases

CMS also clarified reporting requirements for multiple settlements involving the same claimant. The updated guidance confirms that where liability is proportionate or several, but not joint and several, each RRE should report only its own TPOC amount.

CMS added the language in bold:

Multiple settlements involving the same individual – If there will be multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs (proportionate or several liability but not joint and several), the records shall reflect each RRE’s unique TPOC amount and not the aggregate TPOC the beneficiary will be receiving. If more than one RRE has assumed responsibility for ongoing medicals, Medicare would be secondary to each such entity.

Example

If:

The total settlement is $100,000, and
One RRE’s share is $25,000

Then that RRE reports a TPOC amount of $25,000 — not the full settlement amount.

What This Means

This reinforces that reporting obligations where there is not joint and several liability are entity-specific, aligning each RRE’s reporting with its actual financial responsibility and avoiding over-reporting of settlement amounts.

The update helps avoid:

Over-reporting settlement amounts
Duplicate reporting
Confusion around proportional liability scenarios

Medicare Set-Aside (MSA) Reporting Clarifications

CMS also revised guidance regarding WCMSA reporting in cases involving:

Multiple dates of injury, or
Multiple defendants

CMS updated with new information in bold:

“As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting each RRE must report the total MSA Amount—not just its assigned or proportionate share. System logic exists such that only the first reported MSA amount will be applied for purposes of coordination of benefits.”

The updated language states that where multiple RREs are reporting, each RRE must report the full MSA amount — not merely its proportionate share.

CMS further notes that system logic applies only the first reported MSA amount for coordination of benefits purposes.

What This Means

This creates a notable distinction between:

Financial responsibility, and
Reporting obligations

Even where liability is divided, all RREs are required to report the entire MSA amount, making coordination among defendants critical to ensure consistency and avoid confusion.

Example (using the scenario above)

Assume:

Total settlement = $100,000
One RRE’s share = $25,000
WCMSA amount = $50,000

The RRE would report:

TPOC Amount: $25,000
WCMSA Amount: $50,000

Because all RREs must report the full MSA amount, coordination among defendants is critical to ensure consistency and avoid reporting discrepancies.

Final Thoughts

These updates do not fundamentally change Section 111 reporting—but they do tighten expectations around documentation, consistency, and defensibility.

RREs should review internal protocols, particularly around:

ORM termination decisions
Wrongful death claim handling
Coordination in multi-defendant settlements

Small missteps in these areas can create outsized compliance risk.

If you have any questions, please reach out to Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com .

From Backlog to Breakthrough, Reducing 43 Percent of Legacy Claims

May 5, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 8 Reducing Legacy Claims

A large payer came to Tower MSA Partners with a backlog of legacy claims that had stalled for months, and in some cases years. These claims included outdated medical records, unclear treatment histories, and MSAs that had never been reviewed for accuracy. Through structured medical review and focused cleanup, Tower helped the payer resolve 43% of these legacy claims. This case reflects a broader trend in workers’ compensation, where successful legacy claim resolution depends on accurate clinical validation and updated MSA preparation.

Why Legacy Claims Stall

Legacy claims don’t linger because they are unsolvable, they stall because the underlying data is no longer accurate.

In this case:

Treatment histories no longer reflected current care
Medications included in MSAs had long been discontinued
Medical projections were based on outdated assumptions
Files had not been clinically reviewed in years

These issues led to inflated exposure, unclear settlement positions, and hesitation from all parties involved.

Turning Aging Files into Actionable Claims

Tower MSA Partners implemented a structured review process focused on clinical accuracy and defensibility.

Each claim was evaluated to:

Remove discontinued or unnecessary medications
Correct or eliminate outdated treatment projections
Align medical records with current care status
Rebuild MSAs based on actual medical necessity

Tower’s clinical team actively reconciles treatment patterns against real-world care. This ensures allocations reflect what is actually happening—not what was assumed years ago.

The result: MSAs that are accurate, defensible, and ready to support settlement.

How Collaboration Supports Legacy Claim Settlement

Updating the MSA alone is not enough—claims move when all stakeholders are aligned.

Tower worked closely with the claims team to clearly document and explain each change, giving adjusters confidence in the updated exposure. In parallel, structured settlement and professional administration partners were introduced to address claimant concerns about future medical care.

This combination helped:

Reduce claimant resistance
Eliminate uncertainty around future treatment funding
Create cleaner, more predictable submissions to CMS

Files that had been stagnant for years were now positioned for resolution.

Why Legacy Claim Resolution Makes a Difference

Without clinical validation, MSAs drift away from reality over time. They become inflated, difficult to defend, and harder to settle.

Tower’s approach restores alignment between medical documentation and actual care by:

Verifying current treatment status
Eliminating unsupported projections
Ensuring compliance with CMS expectations

This transforms legacy claims from uncertain liabilities into actionable settlement opportunities.

Results That Reflect Expertise

Through a focused legacy claim strategy:

43% of legacy claims were resolved
Previously stalled files became settlement-ready
MSAs were updated to reflect current medical reality
Submissions were supported by clear, defensible documentation

What This Means for Payers

If you have claims that have not moved in years, there is a strong likelihood they are being driven by outdated medical assumptions—not true exposure.

Correcting those assumptions can unlock significant progress without increasing settlement spend.

Ready to Move Your Legacy Claims?

Tower MSA Partners helps payers reduce backlogs, improve MSA accuracy, and accelerate settlements through clinical intervention and disciplined review.

If you’re carrying aging claims that continue to stall, it may be time to reassess what’s driving them.

Contact our team or connect with Hany Abdelsayed, Executive Vice President, Strategic Services, at hany.abdelsayed@towermsa.com to discuss your legacy claim strategy.

Frequently Asked Questions

What is legacy claim resolution?

Legacy claim resolution is the process of reviewing long-standing or stalled claims to correct outdated medical projections and prepare accurate MSAs that support settlement.

Why do legacy claims stall?

They often include outdated treatments, discontinued medications, and unclear medical histories that make MSAs inaccurate or inflated.

How does Tower reduce legacy claim backlogs?

Tower updates records, verifies treatment plans, corrects pharmacy projections, and prepares accurate MSAs supported by current documentation.

Does CMS accept updated MSAs on old claims?

Yes. CMS accepts updated allocations when the documentation accurately reflects the claimant’s current medical needs.

How long does legacy claim resolution typically take?

The timeline depends on the condition of the claim files and the level of medical review required. Many legacy claims can move toward settlement within weeks once records are updated and MSAs are corrected to reflect current medical needs.

$210K Saved: Why Clinical Oversight Is the Hidden MSA Advantage

April 9, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 7 Clinical Oversight Savings

In Tower MSA Partners’ last post, $231K in Savings from Free Physicians Follow-Up, we demonstrated how ongoing medical review produced $231K in savings through free physician follow-up. This month, we highlight the broader impact of clinical oversight itself. A payer asked Tower MSA Partners to review a complex claim involving long-term pain management, active comorbidities, and multiple prescribing providers. Through clinical oversight, Tower identified inaccuracies and outdated treatments that reduced the projected allocation by $210,143 (approximately $210K). This case reinforces why clinical insight is a powerful advantage in Medicare Set-Aside (MSA) management.

Identifying the Problem

The claim had a long history of treatment, frequent medication changes, and overlapping specialties that created inconsistencies in documentation. The initial MSA prepared by another vendor included medications that were no longer prescribed, therapy frequencies that were inconsistent with current care, and several treatments that lacked documentation supporting ongoing medical necessity. Without clinical oversight, these issues would have resulted in inflated costs and potential CMS challenges. The payer needed an accurate allocation that reflected the claimant’s present health status and documented treatment plan.

The Clinical Oversight Solution

Tower MSA Partners conducted a comprehensive clinical review of all medical records, pharmacy histories, diagnostic reports, and provider notes. The clinical team identified medications that had been discontinued, adjusted prescription regimens based on updated records, and corrected treatment frequencies. The review also uncovered redundant therapies that no longer aligned with best practice guidelines. Each correction was supported with clinical rationale and evidence-based justification. After applying these corrections, the revised MSA decreased by $210K while meeting all CMS expectations for accuracy and documentation.

Collaboration and Communication

Tower’s team worked closely with the claims professional to explain each update and its clinical foundation. Clear communication ensured that all parties understood the reasoning behind each correction. Defense counsel and treating providers were involved as needed to validate treatment patterns and confirm medication changes. This collaborative approach helped create a strong, defensible MSA that moved through CMS review without additional development requests. Precise documentation and clinical clarity built confidence across the entire review chain.

Why Oversight Makes the Difference

Clinical oversight strengthens MSA accuracy by applying an evidence-based medical lens instead of a purely administrative review, ensuring allocations are clinically appropriate and defensible under CMS review. Over time, complex claims develop treatment patterns that do not always reflect current clinical standards or actual patient needs. By applying clinical judgment, Tower identifies outdated or unnecessary items that inflate lifetime costs and weaken compliance. This case shows how oversight protects payers from significant overfunding while ensuring the MSA remains a true reflection of medically necessary care.

Lessons Learned

· Clinical oversight reveals inconsistencies that administrative reviews often miss.

· Updated medical documentation ensures accurate and defensible MSA projections.

· Collaboration with providers strengthens clarity around treatment plans.

· Savings come from clinically guided corrections and accurate projections.

· The $210K reduction resulted from correcting outdated services and aligning projections with best practice.

Results That Reflect Expertise

The payer saved $210K and gained a fully compliant, defensible MSA supported by updated medical documentation and evidence-based clinical review. Tower MSA Partners demonstrated how clinical insight delivers meaningful savings while strengthening the accuracy and defensibility of every allocation. Clinical oversight is an essential advantage in managing complex claims and achieving both cost containment and compliance excellence.

FAQs

What is clinical oversight in MSA review?
Clinical oversight is a medically guided evaluation of an MSA that ensures treatments and medications reflect current clinical standards and documented medical necessity.

How does clinical oversight reduce MSA costs?
It identifies outdated treatments, incorrect therapy projections, and discontinued medications that inflate lifetime medical costs.

When is clinical oversight most valuable?
It is essential for complex claims involving long-term treatment, multiple providers, or frequent medication changes.

Does CMS recognize clinically supported changes?
Yes. CMS accepts proposed MSA amounts when they are supported with accurate clinical documentation and clear reasoning.

Premier Webinar: MSP Compliance in 2026 – Regulatory Updates, Section 111 Audits & Settlement Risk

March 9, 2026

Tower MSA Partners webinar banner for “MSP Compliance in 2026, Section 111 Audits and Settlement Risk” on March 11, 2026 at 2 PM ET.

In 2025, the Medicare Secondary Payer landscape changed in meaningful ways. Section 111 WCMSA reporting became operational, and CMS discontinued formal review of $0 MSAs—fundamentally altering how payers approach settlement strategy and compliance risk.

Now in 2026, CMS is preparing to initiate its first round of Section 111 reporting audits.

What does all this mean for carriers, self-insureds, and defense counsel?

On Wednesday, March 11 at 2:00 p.m. ET, join Tower’s Chief Compliance Officer, Dan Anders, for a focused, practical discussion on how these regulatory developments are impacting workers’ compensation claims handling—and what organizations should be doing now.

You will learn:

The current status of Section 111 WCMSA reporting and how it is affecting settlement negotiations
What to expect from upcoming CMS Section 111 audits, including likely audit focus areas and compliance vulnerabilities
How to evaluate and document $0 MSAs in the absence of formal CMS review
Emerging MSA trends based on recent CMS guidance and Tower benchmarking data
Practical steps to mitigate civil money penalty exposure and strengthen internal controls

A Q&A session will follow the presentation. Questions may be submitted in advance during registration.

Please reserve your spot today.

Registration link: https://attendee.gotowebinar.com/register/3480677134558573406

$231K in Savings from Free Physician Follow-Up

March 4, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 6 $231K in Savings from Free Physicians Follow-Up.

In Tower MSA Partners’ previous post, Trimming the Fat, $175K in Savings Through MSA Optimization, we explained how MSA optimization removed $175,000 in unnecessary projected costs. In this case, a payer asked Tower to validate the treatment plan for a complex claim through physician follow-up. By engaging the treating provider, confirming current medical needs, and obtaining a physician attestation, Tower reduced the projected Medicare Set Aside (MSA) lifetime cost by $231,487 and secured CMS acceptance without development.

Identifying the Problem

The claimant’s original MSA had been created more than two years earlier. Since that time:

Multiple prescriptions were listed without up-to-date clinical context
Treatment frequency and diagnoses were not validated
The projected costs reflected outdated assumptions

Without direct clinical confirmation, the allocation risked inflating projected future costs and faced potential CMS scrutiny. The payer needed a defensible allocation grounded in current medical reality.

The Physician Follow-Up Solution

Tower’s clinical team initiated physician follow-up, adhering to jurisdictional rules for secure outreach. The process included:

Reviewing the full set of updated medical records
Confirming active medications, dosages, and indications
Discussing current therapy frequency with the treating physician
Validating the absence or tapering of unnecessary prescriptions

The physician confirmed that the only active prescription was Oxycodone/APAP 5/325 mg and that certain therapies were no longer needed. Armed with this clinical confirmation and a signed attestation, Tower updated the allocation.

The result was a $231,487 reduction in projected MSA costs — fully documented, fully supported, and defensible.

Collaboration and Communication

Tower MSA Partners didn’t just update numbers in a spreadsheet. Every correction was explained clearly to the claims professional and documented. The physician’s signed attestation — verifying current care and confirming that outdated items were no longer clinically necessary — was included in the CMS submission.

Because the revised MSA included accurate current clinical information and a valid attestation, CMS approved the allocation quickly and without development requests.

Why Physician Follow-Up Makes the Difference

Treatment plans evolve, medications change, and assumptions in an early allocation can become outdated. Without direct validation from the treating physician:

Medications may be mischaracterized
Frequencies may be overstated
Lifetime projections may overestimate future care

Physician follow-up ensures the MSA reflects actual current need, which:

Controls costs
Enhances compliance
Strengthens defensibility in CMS review

This case shows that physician engagement isn’t a luxury — it’s a strategic lever for both accuracy and savings.

Lessons Learned

Physician engagement validates clinical need and clarifies current care.
Signed attestations give CMS confidence in the accuracy of the allocation.
Outdated medications and therapies can be confidently removed when confirmed to be clinically unnecessary.
Defensible projections protect payers from excess costs and speed CMS review.

Results That Reflect Expertise

With targeted physician follow-up and attestation:

The payer realized $231,487 in reduced lifetime MSA costs
The updated allocation aligned with clinical reality
CMS approved the allocation without development requests

Tower MSA Partners delivered transparent documentation, accurate projections, and a cost-conscious, defensible settlement outcome.

FAQs

What is physician follow-up?

Physician follow-up is direct communication by Tower with the treating provider to confirm current medical treatment, active medications, and therapy needs. It ensures MSAs reflect accurate, individualized clinical information.

How does physician follow-up create savings?

By validating care with the treating physician, unnecessary treatments and medications can be removed or corrected in the lifetime projection, reducing projected future costs.

Is physician follow-up accepted by CMS?

Yes. When physician follow-up includes clear clinical documentation and, if required, a signed statement, CMS will accept updated MSAs and often approves them without development requests.

When should physician follow-up be used?

Physician follow-up can be used anytime there is open-ended medical care, outdated treatment recommendations or inconsistent or contradictory medication history.

Trimming the Fat, $175K in Savings Through MSA Optimization

February 3, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 5 Trimming the Fat with MSA Optimization

In Tower MSA Partners’ previous post, we showed how a MSA second opinion review helped a payer avoid ninety-eight thousand dollars in unnecessary allocation. This month, we look at a case study on how targeted MSA optimization can uncover even larger savings. Tower MSA Partners reviewed a complex claim with significant pharmacy exposure and identified an opportunity to reduce projected costs by $175,000. This case shows how structured review protocols and clinical oversight create precise and defensible MSAs.

Identifying the Problem

The claimant had a long-term injury that included frequent therapy, diagnostics, and multiple ongoing prescriptions. The initial MSA prepared by another vendor included duplicate entries, outdated treatments, and medications that had been replaced with safer and more cost-effective alternatives. Therapy frequency was also projected far beyond what the medical records supported. These inaccuracies created an inflated allocation that did not reflect current treatment patterns.

The MSA Optimization Solution

Tower MSA Partners completed a full optimization review and reconciled every projection with the latest medical records. Our clinical team verified treatment frequency, evaluated pharmacy histories, and confirmed whether each medication remained clinically appropriate. Outdated therapy, legacy prescriptions, and inaccurate frequency projections were removed or corrected. Each modification included detailed clinical reasoning and clear documentation. After optimization, the MSA decreased by $175,000 and remained fully aligned with CMS expectations. The updated allocation represented the claimant’s true medical needs without unnecessary inflation.

Collaboration and Communication

As with all Tower reviews, collaboration played a significant role. The clinical team walked the claims professional through each correction and clarified why the original allocation overstated ongoing care. Defense counsel and treating providers were updated as needed to confirm accuracy and alignment with the medical record. The optimized MSA was submitted to CMS with strong supporting documentation and was approved without development requests.

Why Oversight Makes the Difference

MSA optimization is not simply cost-cutting. It is a structured validation process that ensures every projected service is clinically necessary and supported by current documentation. Removing outdated items protects payers and claimants from unnecessary costs and strengthens the defensibility of every file. This case demonstrates how careful review drives savings.

Lessons Learned

MSA optimization identifies inaccurate or outdated projections that inflate lifetime medical costs.
Clinical oversight ensures medications and treatments reflect current best practice.
Documentation clarity leads to predictable CMS approval.
Savings come from precision. The $175,000 reduction resulted from accurate alignment with the medical record.

Results That Reflect Expertise

The optimized MSA saved the payer settlement monies and produced a compliant, defensible allocation supported by current documentation. Tower MSA Partners continues to demonstrate how clinical accuracy, alignment with CMS, and detail-oriented review generate meaningful and measurable results. Optimization is an essential tool in responsible claims management.

FAQs

What is MSA optimization

MSA optimization is a detailed clinical review that removes outdated treatments, corrects inaccurate projections, and ensures the allocation reflects current medical necessity.

How does optimization reduce allocation amounts

Optimization aligns treatment and pharmacy projections with the actual medical record, which eliminates unnecessary costs and outdated services.

When should an MSA be optimized

It is recommended for claims with long-term treatment, complex pharmacy needs, or significant changes in care since the initial projection.

Does CMS accept optimized MSAs

Yes. CMS accepts optimized MSAs when the updated allocation includes clear clinical documentation and accurate reasoning for the projected future medical.

A $98K Mistake Avoided, The Value of Second Opinion MSA Reviews

January 12, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 4 A $98K Mistake Avoided with a Second Opinion MSA Review

In Tower MSA Partners’ previous post, we explained how Physician Peer Review generated more than one million dollars in savings while strengthening CMS compliance. This month, we shift focus to the importance of accuracy. Tower MSA Partners was asked to review a Medicare Set Aside allocation prepared by another company, and the findings revealed a significant error that would have cost the payer ninety eight thousand dollars. This case illustrates why a second opinion is a valuable safeguard in every MSA strategy.

Identifying the Problem

The claim involved ongoing treatment, therapy, and pharmacy exposure. The original MSA prepared by another vendor appeared complete, and the projected costs seemed typical for this type of injury. Once Tower MSA Partners reviewed the file, the clinical team found inconsistencies that required deeper investigation. Several treatment projections did not align with the documented medical record. The file also listed duplicate items and outdated medications that had already been removed from the claimant’s regimen. The largest issue involved a discontinued high-cost prescription that remained in the allocation. This error inflated the MSA by nearly one hundred thousand dollars and created unnecessary CMS risk. If submitted as written, the payer would have funded care that no longer existed and faced questions about clinical justification.

The Second Opinion Solution

Tower MSA Partners completed a complete second opinion MSA review. Analysts verified each treatment recommendation and cross-referenced records with the most current documentation. Pharmacy history was compared to recent physician notes to ensure accuracy. The discontinued medication was the key discrepancy. The treating physician had replaced it with a lower cost, safer alternative, and the original reviewer failed to revise the allocation. Tower updated the MSA to reflect the correct medication plan and documented the clinical reasoning in clear, concise terms. With the correction in place, the projected cost of the MSA decreased by ninety-eight thousand dollars while maintaining complete alignment with CMS guidance.

Collaboration and Communication

Tower MSA Partners emphasizes transparency in every step of the review. The clinical team explained each correction and helped the claims professional understand why the original allocation was inaccurate. This clarity supported confident decision making and prepared the file for CMS submission. Tower also communicated updates with the defense attorney and treating provider, so all parties understood the medical basis for the revisions. When submitted to CMS, the revised MSA was approved without development requests. Accurate documentation and clinical alignment created a predictable approval process.

Why Oversight Makes the Difference

Accuracy is essential in Medicare Set Aside management. Even a small oversight can inflate lifetime medical projections and expose the payer to avoidable costs. A second opinion MSA review provides an essential layer of validation that confirms medical necessity, eliminates outdated information, and protects the overall integrity of the claim. This case demonstrates that clinical oversight and cost savings work together. Correcting the allocation not only protected the payer from unnecessary spending but also ensured that the file met CMS expectations with confidence.

Lessons Learned

A second opinion review prevents costly mistakes and confirms accuracy before submission.
Outdated information leads to inflated costs, especially in pharmacy heavy claims.
Strong clinical documentation makes CMS approval predictable and efficient.
Precision drives savings. The ninety-eight-thousand-dollar reduction resulted from careful review and experienced analysis.

Results That Reflect Expertise

By requesting a second opinion, the payer avoided a ninety-eight thousand-dollar over allocation and gained a compliant, defensible Medicare Set Aside. The corrected review reflected actual medical necessity and prevented unnecessary long-term funding. This case highlights Tower MSA Partners’ continued commitment to accuracy, clinical alignment, and cost containment. A second opinion review is more than a quality check. It is an essential safeguard for payers, claimants, and settlements.

FAQs

What is a second opinion MSA review?

A second opinion review evaluates an MSA prepared by another company to confirm accuracy, clinical validity, and compliance with CMS guidelines.

How do second opinions create savings?

They uncover outdated treatments, discontinued prescriptions, and projection errors that inflate total costs.

When should a second opinion be considered?

Any claim with complex medical history, high pharmacy exposure, or uncertainty about the accuracy of an existing MSA benefits from a second opinion.

CMS 2025 WCMSA Metrics Show Ongoing Decline in WCMSA Reviews and Rx Costs

December 15, 2025

CMS Metrics Show Ongoing Decline in WCMSA Reviews & Rx

The Centers for Medicare and Medicaid Services’ (CMS) newly released 2025 Workers’ Compensation Medicare Set-Aside (WCMSA) fiscal year statistics provide fresh insight into five years of CMS activity, comparing proposed MSA amounts with CMS-recommended (or “approved”) amounts.

This year’s data reveals a notable shift: CMS MSA recommendations – the number of completed reviews where CMS issues a recommended amount – have decreased by 12% since 2023 following a prior year increase. These insights offer valuable context for payers evaluating settlement strategies and benchmarking partner performance.

Below is a clear, easy-to-read summary of CMS’s latest data and how Tower’s results compare.

CMS MSA Recommendations are Down 12%

The agency provided five years of data covering 2021 to 2025 (CMS’s fiscal year ends on September 30), comparing proposed MSA amounts with CMS-recommended (often referred to as “approved) amounts. CMS MSA recommendations represent completed CMS reviews in which the agency issues the recommended amount needed to protect Medicare’s interest.

After a 9% increase in CMS MSA recommendations between 2022 and 2023, the 2025 data shows a 12% decrease in recommendations since 2023. The five-year average for CMS MSA recommendations is 14,611. No reason is provided for the decline; however, the end of Zero MSA reviews this past July likely contributed to this reduction.

Average MSA Amounts Hold Steady

The average CMS MSA amount increased slightly from $85,927 in 2024 to $86,169 in 2025, which is higher than the five-year average of $84,172.

A major trend persists: the widening variance between proposed and CMS-recommended amounts. In 2025, the variance reached 24% – the highest level in the past five years – resulting in more counter-highers to CMS MSA submissions.

Prescription Medication Costs Down; Treatment Costs Stable

Prescription drug costs have steadily decreased over the past five years. The average CMS-recommended amount is now $17,501—down 16% over the past five years. Treatment costs in the MSA have remained consistent year over year but are still up 13% over the five-year span.

How Tower’s MSAs Stack Up

Tower’s CMS-approved MSAs are consistently lower than the industry average CMS-approved MSAs, which is reflected in a comparison between CMS and Tower’s metrics.

Average Approved MSA (2025):

CMS: $86,169 Tower: $66,900

Tower’s average CMS-approved MSAs are 23% lower than the average CMS-approved MSA.

If we isolate just the prescription drug component of the MSA:

Average Rx Amount in MSA (2025):

CMS: $17,501 Tower: $11,701

Tower’s prescription drug allocations are 33% lower than the CMS average.

These metrics indicate that cost reductions are possible when payers select the CMS MSA approval process. Tower’s MSA allocation methodology and cost mitigation efforts, such as our Physician Follow-up service, effectively lower MSA allocations.

Why These Metrics Matter

CMS’s annual data release provides valuable transparency into review trends and serves as a helpful benchmark for the industry. Ultimately, partner performance drives payer outcomes. Tower’s results demonstrate that when clinical precision, compliance strategy, and operational execution come together, CMS approval can be both achievable and cost-effective.

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