Misc Archives - Tower MSA

Tower’s Physician Follow-Up Service Kicks Costly SCS Out of MSA

June 20, 2024

Save-Medicare-Set-Asides-with-Tower's-Physician-Follow-Up-service.

Nothing can stall settlement faster than a Medicare Set-Aside (MSA) that includes an unnecessary or unwanted medical procedure. Procedures like surgeries, spinal cord stimulators (SCSs), and intrathecal pain pumps significantly raise the costs of MSA allocations. Fortunately, Tower’s client partners have access to our complimentary Physician Follow-up service that Save on MSAs.

In a recent case, this service successfully removed a costly SCS from the MSA, resulting in a savings of $132,232.

Challenges with SCS Trial Inclusion in MSAs: Addressing Worker Reluctance and CMS Requirements

A worker who had suffered a low back injury was advised by his neurosurgeon and pain management physician to consider an SCS trial. A review of treatment records showed that the injured worker was very anxious about the procedure, and a psychological evaluation revealed a diagnosis of major depressive disorder.

Despite the worker’s reluctance to undergo the procedure, CMS will include it in the MSA, assuming that the worker may change their mind. Tower drafted an initial MSA to include the SCS for a total allocation of $157,500.

Successfully Removing SCS from MSA with Physician Statements: Tower’s Approach

The injured worker’s resistance to the procedure and results of the psych evaluation indicated he would not be a suitable candidate for an SCS. Therefore, we recommended that our Physician Follow-up service obtain statements from both physicians that confirmed the SCS is no longer part of the treatment plan. (If only one physician had provided a statement, CMS would likely keep the SCS in the MSA).

After client approval, in compliance with this jurisdiction’s regulations, Tower notified the plaintiff’s attorney of our intention to communicate with the injured worker’s providers. We then contacted the neurosurgeon and pain management specialist and provided them drafts of physician statements that confirmed the SCS is no longer a treatment option.

While it took several weeks of persistent follow-up with the physicians’ offices, Tower successfully obtained both signed statements.

Efficient MSA Revision: Tower Achieves Significant Cost Reduction and Quick CMS Approval

Tower revised the MSA down from $157,500 to $25,268 and submitted it to CMS. CMS approved the MSA within two weeks for the proposed amount.

In response, Tower’s client said, “Great job, Tower! I am so thankful for our partnership and truly appreciate your hard work and persistence. $132k in savings!!! Woohoo!”

The defense attorney said, “you guys work some real magic here, bravo!”

It’s more methodology than magic, but we often find opportunities to reduce the allocation or mitigate potential increases from CMS review when we draft an MSA. Vague references to potential future procedures mean these costs will be included in the MSA. CMS’s exacting review process requires explicit confirmation of the last dates of service and ongoing treatment and medications.

At no extra charge, Tower contacts physicians, clarifies treatment, drafts physician statements, and obtains medical providers’ signatures to document dates of treatment and ongoing and future medical care. This service paves the way to quick CMS MSA approval and mitigates the potential for unexpected increases.

To learn more about our Physician Follow-up service, please get in touch with Hany Abdelsayed at 888.331.4941 or hany.abdelsayed@towermsa.com.

How to Manage Medicare Set-Asides: Tips from Dan Anders

May 29, 2024

Our Chief Compliance Officer Dan Anders learned how to write Medicare Set-Asides (MSA) the hard way through trial and error in the days before the Centers for Medicare and Medicaid published complete guidelines. Even now, the manuals and regulations don’t cover every detail.

And with MSAs details matter. Proper documentation, down to the way the claimant signs and initials their consent form, is essential. Dan compiled some tips for managing MSAs with CMS in his May 21 Leaders Speak article for WorkCompWire. These are among the topics covered:

Rated ages

The article highlights the use of rated ages as a way to calculate a fair allocation for the MSA. Briefly, if an injured worker has comorbidities that will likely reduce their longevity, a rated age can reduce the allocation of the MSA.

How to respond to a dreaded Development Letter from CMS

Dan tells readers how to respond to a CMS Development Letter, which CMS sends when it needs additional information to review submitted MSA. These letters usually request updated treatment records, complete claim payment history of medical, indemnity and expenses, or a document that clearly outlines all the dates of injuries, all carriers, and all accepted and denied body parts.

Development letters can be avoided with the submission of all the correct documents with the MSA. Some submissions provide an Independent Medical Evaluation or Qualified Medical Evaluator report in lieu of medical records. IMEs, QMEs and similar evaluations may influence a decision, but they cannot replace treatment records. And CMS wants ALL the injury-related records even if workers’ compensation did not pay for the treatment.

When to request a Re-Review

Dan also explains how to handle the Re-Review Appeal process. CMS can make mistakes when issuing counter-highers. He cites several common mistakes, including incorrect prescription drug pricing, misinterpretation of medical records, and using the wrong fee schedule. Always analyze counter-highers for potential errors and consider taking advantage of this appeal.

Tower is here to help manage Medicare Set-Asides

Read the article here and remember that Tower consults with its clients on every aspect of MSA submission and other Medicare Secondary Payer issues. Whether you’re a client yet or not, Dan is available to discuss issues you encounter with your MSAs. Contact him at daniel.anders@towermsa.com.

CMS Moves Start Date for WCMSA Reporting to April 2025

April 23, 2024

CMS delays start date for Section 111 reporting of WCMSAs to April 2025 and announces new webinar for Q&A

During last week’s webinar, the Centers for Medicare and Medicaid Services (CMS) announced an extension of the start date for Section 111 reporting of WCMSAs from January 2025 to April 4, 2025.

(Due to technical difficulties with the April 16 webcast, CMS has scheduled another webinar for Q&A this Thursday, April 25, 2024, at 2:30 ET. Details on the webinar are here.

Remember, CMS requires Section 111 reporting of WCMSAs of any MSA amount, even if $0. These amounts must be reported whether they are CMS-approved MSAs or not.

CMS details new reporting guidelines and start date for Section 111 WCMSA Implementation

CMS reiterated several points that had been detailed in a prior webinar and through the recent Section 111 User Guide update. Please review CMS Updates Section 111 NGHP User Guide and WCMSA Reference Guide for this information. New points are below:

The start date for WCMSA reporting was changed from January 2025 to April 4, 2025, to give Responsible Reporting Entities (RREs) more time to make the needed changes to their reporting processes.
Testing of the new fields will be available beginning on October 7, 2024.
All WCMSA fields except Field 43 (Professional Administration EIN) will result in “hard” errors if reported incorrectly. Hard errors cause the TPOC report to be rejected, which can in turn cause the report to be untimely if it is not corrected promptly.
As such, hard errors may result in the imposition of civil money penalties (CMPs) although CMS will not impose a CMP for two reporting periods after implementation of WCMSA reporting. In other words, only records on or after October 15, 2025, and with a reportable MSA are subject to a CMP.
If an RRE fails to report an MSA, CMS may utilize all available statutory and regulatory options to recover mistakenly made payments, including under the False Claims Act.
No changes are made as to what constitutes a reportable TPOC. If a TPOC is reportable, then the WCMSA fields must be completed. If it is not reportable, such as when the WC settlement is $750 or less, then the WCMSA fields are not completed.
If multiple defendants are parties to a single settlement, they must report the total TPOC amount (and not their “share”) and the total MSA amount.
The Section 111 reporting process is not intended to replace the submission of settlement documents to CMS following the settlement of a claim with a CMS-approved MSA. (Final settlement documents should always be sent to Tower for upload to CMS.)
Receipt of the MSA report through the Section 111 reporting process will allow CMS to send information to the beneficiary on the attestation and exhaustion process. (Currently this is not done for most self-administered non-submit MSAs).

CMS outlines impact of “W” records in common working file (CWF) for MSA reporting

CMS also explained that once the MSA is reported, a “W” record will be posted in the Common Working File (CWF), which prevents payments of medical services related to the reported diagnosis codes. The CWF is part of CMS’s system to accurately coordinate benefits, so Medicare does not make payment when another “primary payer” is available.

A copy of the webinar slides can be found here.

Please contact Dan Anders at daniel.anders@towermsa.com with any questions.

CMS Updates Section 111 NGHP User Guide and WCMSA Reference Guide

April 5, 2024

CMS Releases Updates to MMSEA Section 111 NGHP User Guide and WCMSA Reference Guide

The Centers for Medicare and Medicaid Services (CMS) began April with updates to two of its popular user guides, the MMSEA Section 111 NGHP User Guide and the WCMSA Reference Guide. Notably, the NGHP User Guide, version 7.5, now includes details on the requirements to report WCMSA amounts with other relevant data. These will need to be reported as of April 4, 2025.

The NGHP User Guide, Section 6.5.1.1 of Chapter III: Policy Guidance, was updated to state:

For workers’ compensation records submitted on a production file with a TPOC date on or after April 4, 2025, Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) must be reported.

CMS also updated Chapter IV: Technical Information with similar language.

CMS Revisions to WCMSA Reporting Fields in Chapter V: Appendices

Additionally, CMS updated Chapter V: Appendices to identify the fields that will be added to the Claim Input File Detail for WCMSA reporting:

Field 37 – MSA Amount: This will be either $0 or an amount greater than $0. If an annuity is used, then the “total payout” is reported.
Field 38 – MSA Period: If the MSA amount is greater than $0, you need to enter the number of years the MSA is expected to cover the beneficiary.
Field 39 – Lump Sum or Structured/Annuity Payout Indicator: If the MSA amount is greater than $0, you will enter “L” for a lump-sum MSA or “S” for a structured/annuity MSA.
Field 40 – Initial Deposit Amount: If an annuity, then the MSA seed amount is reported.
Field 41 – Anniversary Deposit Amount: If an annuity, then the amount of the annual payments.
Field 42 – Case Control Number (CCN): If an MSA is submitted to CMS for review or is otherwise submitted to CMS post-settlement, it will be assigned a CCN. The CCN is entered in this field, although this is optional.
Field 43 – Professional Administrator EIN: Enter the Employer Identification Number of the professional administrator here if there is one. If this EIN is not provided, the “case administrator” defaults to the beneficiary. If the EIN does not match a registered administrator account in the Workers Compensation Medicare Set-Aside Portal (WCMSAP), then “case administrator” will also default to the beneficiary.

CMS provided a table of error codes for errors identified in the above-reported information.

Responsible Reporting Entities (RREs) can start testing these new fields on October 7, 2024. For further details, see the Tower article, CMS Sets Date for Start of Section 111 WCMSA Reporting.

CMS also incorporated the following notice into the NGHP User Guide:

As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain 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 (Section 6.4).

The $750 reporting threshold has been in place for several years.

CMS included minor updates to the WCMSA Reference Guide, version 4.0

Specifically, CMS added:

Instruction specific to beneficiaries has been added to encourage them to use their Medicare.gov access to the portal for the most efficient method of submitting attestations (Sections 11.1.1 and 17.5).

For further information on electronic reporting of attestations, see the above-referenced sections in the guide or the Tower article, CMS Adds Electronic Submission Option for MSA Attestations.

CMS also amended the link in Section 10.3 to reflect the most recent CDC Life Table link. The life tables are used to determine life expectancy for calculation of the MSA.

CMS Sets April 16 for Webinar on Section 111 Reporting of WCMSAs

March 27, 2024

Prepare for Change: CMS Webinar on Expanding Section 111 NGHP TPOC Reporting to Include WCMSA Information

The Centers for Medicare and Medicaid Services has scheduled a webinar for April 16, 2024, at 2 PM ET to provide updates on the implementation of Section 111 reporting of Workers Compensation Medicare Set-Asides (WCMSAs). Per the March 25, 2024 announcement:

CMS will be hosting a second webinar regarding the expansion of Section 111 Non-Group Health Plan (NGHP) Total Payment Obligation to Claimant (TPOC) reporting to include Workers’ Compensation Medicare Set-Aside (WCMSA) information. After the first webinar in November, CMS received additional questions and feedback from the industry. The intent of this webinar is to ensure that RREs will be prepared for the change once implemented. With that in mind, this webinar will include a background recap, summary of technical details, updated timelines and CMP impacts. The presentation will be followed by a question and answer session. Because this expansion impacts reporting of WCMSAs, it is strongly recommended that Responsible Reporting Entities (RREs) that report Workers’ Compensation settlements attend.

There is no pre-registration for the webinar. Full details can be found here.

As of April 4, 2025, TPOC reporting must include Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs). (See CMS Sets Date for Start of Section 111 WCMSA Reporting).

The WCMSA reporting requirement applies to both CMS-approved and non-approved MSAs. This information must be reported if the insurance type is workers’ compensation and the TPOC amount is greater than $0. The rule will be prospective only, meaning it applies to TPOC dates of April 4, 2025 and later.

To collect this data, CMS is adding new fields to the Section 111 Claim Input File.

Tower will provide a post-webinar summary. If you have any questions, please contact Dan Anders at daniel.anders@towermsa.com or 888.331.4941.

Tower MSA Chief Compliance Officer featured in WorkCompWire Leaders Speak Series

May 29, 2018

Tower MSA Partners’ Chief Compliance Officer, Dan Anders, is featured this month in the WorkCompWire Leaders Speak series with two articles.

In the first article, Don’t Get Taken Advantage of by Medicare Advantage, Dan provides an easy to understand explanation as to why Medicare Advantage plans can seek reimbursement in workers’ compensation claims and the steps necessary to resolve such reimbursement claims.

In the second article, Building a Better Relationship with your MSA Vendor, Dan discusses how active engagement with your MSA vendor results in a beneficial partnership to settle claims and lower claims costs. The article addresses such matters as the importance of reading the MSA report, creating an escalation process and monitoring key performance metrics.

WorkCompWire’s Leaders Speak highlights the thought leaders in the field of workers’ compensation. In a series of articles, professionals throughout the industry bring forth their ideas, thoughts, and research to matters most impacting the day-to-day handling of workers compensation claims.