May 25, 2018
Tower MSA Partners is proud to be an Exhibitor and Sponsor at the 27th Claims Management & Leadership Conference, June 10th-13th, 2018 at the beautiful Hyatt Regency Coconut Point, Bonita Springs, FL.
Stop by our booth to meet Kathleen Losada, V.P. of Strategic Services and learn about Tower MSA Partners Technology Driven MSP Compliance.
You can also contact Kathleen directly to schedule a meeting at Kathleen.losada@towermsa.com or 561-609-9313.
March 1, 2018
Effective March 19, 2018, Capitol Bridge, LLC will be taking over responsibilities from Provider Resources as CMS’s Workers Compensation Review Contractor (WCRC). CMS has now announced a webinar set for Wednesday, March 7, 2018 at 1:00 PM ET to introduce the new MSA review contractor. See CMS Notice which includes a link to register for the webinar.
Capitol Bridge becomes the third company since 2003 to be awarded the WCRC contract. The contractor is charged with evaluating Workers’ Compensation Medicare Set-Aside (WCMSA) proposals submitted to CMS for review and approval. Using criteria set by CMS, it makes recommendations to the designated CMS Regional Office (RO) as to whether the proposed MSA amount adequately protects Medicare’s interests. If the WCRC disagrees with the proposal it will provide an alternate recommendation, either higher or lower, than the proposed amount. The CMS RO usually accepts the recommendation from the WCRC and issues the approval letter to the submitter of the MSA.
Besides the transition to the new contractor, what is unique about Capitol Bridge’s contract with CMS is the inclusion of a provision providing for the optional expansion of its MSA review responsibilities to liability and no-fault cases as early as July 1, 2018. We caution though that CMS has not announced that such an expansion will occur on July 1, 2018.
Tower MSA applauds CMS for inviting those impacted by the contractor change to this introductory webinar. On the heels of the January webinar introducing the new CRC contractor, we are pleased with more transparency by CMS in its process and policy changes. If you are unable to attend CMS’s webinar, Tower MSA will provide a summary of relevant information on our MSP Compliance Blog following the presentation.
January 21, 2018
On Thursday, January 18, 2018, the Centers for Medicare and Medicaid Services (CMS) held a webinar to introduce the new Commercial Repayment Center (CRC) contractor, Performant Recovery, and Performant’s management team. This transition to a new contractor is important to insurers and employers as the CRC is responsible for the recovery of Medicare conditional payments against these entities stemming from liability, workers’ compensation and no-fault claims where ongoing responsibility for medicals has been accepted.
Ted Doyle, the Performant MSP CRC Project Director, emphasized in his introductory remarks and throughout the presentation that their main goal is to make the transition seamless for all those who engage with the CRC. His message to stakeholders is CMS’s recovery processes and timeframes remain the same, it is only the entity handling those processes that is changing.
Besides Mr. Doyle, other webinar participants were John Albert, the Director of the CMS Division of Medicare Benefit Coordination and Laura Martinez, the MSP CRC NGHP Recovery Manager for Performant.
Key contractor transition information provided during the webinar was as follows:
In regard to what will remain the same post-transition:
As for what is changing post-transition:
*Any correspondence received prior to 2/12/2018 will be held and then processed starting on that date.
As with any transition, some bumps are to be expected. We are hopeful these will be short-term and that the transition will not only be seamless, but that Performant improves the customer service aspect of the Medicare conditional payment recovery process. CMS and Performant engaging with Tower MSA and other stakeholders through this webinar is a good first step at building a collaborative relationship with those impacted by the CRC’s recovery efforts.
It was indicated a copy of the presentation slides will be made available on the downloads section of the CMS Coordination of Benefits and Recovery website next week.
If you have any questions regarding the CRC contractor transition, please contact Dan Anders at daniel.anders@towermsa.com or (888) 331-4941.
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Daniel Anders, Esq., MSCC Daniel M. Anders is the Chief Compliance Officer for Tower MSA Partners where he oversees the Medicare Secondary Payer (MSP) compliance program. Dan is an attorney licensed to practice in the State of Illinois and the United States District Court for the Northern District of Illinois. |
January 9, 2018
On Thursday, January 18, 2018, at 1:00 PM ET, the Centers for Medicare and Medicaid Services (CMS) will host a webinar for the purpose of introducing the new Commercial Repayment Center (CRC) contractor to Non-Group Health Plans.
The CRC is responsible for recovery of Medicare conditional payments from liability insurers (including self-insured entities), no-fault insurers and workers compensation entities where such entities are the identified debtor by Medicare. It was announced last October that the new CRC contract had been awarded to Performant Financial Corporation (See Tower MSA article: New Commercial Repayment Center Contractor on the Horizon). The transition to the new contractor is to occur on February 8, 2018.
According to the January 5, 2018 CMS Notice, the webinar will consist of opening remarks and a presentation by CMS followed by a Q & A session. We encourage anyone who has regular contact with the CRC to register and attend the presentation (A link to register is located in the CMS Notice). If you are unable to attend, Tower MSA will provide a summary of relevant information on our MSP Compliance Blog following the presentation.
As CMS contractor changes are often fraught with a subsequent period of longer turnaround times and inconsistent communication with contractor representatives, we hope this transition proves an exception to past experiences. This introductory webinar appears to be a useful first step.
If you have any questions regarding the CRC contractor transition, please contact Dan Anders at daniel.anders@towermsa.com or (888) 331-4941.
January 3, 2018
Pursuant to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, CMS is required to transition all Medicare beneficiaries from the Social Security Number based Health Insurance Claim Numbers (HICNs) to a new identification number called a Medicare Beneficiary Identifier (MBI). The primary purpose of this initiative is to reduce identify theft associated with use of Social Security Numbers in HICNs.
Accordingly, starting in April 2018 CMS will begin to mail new cards with the new Medicare numbers to Medicare beneficiaries. The goal is to issue all new cards by April 2019. For medical providers, there will be a transition period from 4/1/2018 through 12/31/2019 in which either the HICN or MBI will be accepted for processing of payments by Medicare.
Minimal Impact on Section 111 Reporting
Unlike medical providers which must exclusively use the MBI by 1/1/2020, as explained in the updated Section 111 NGHP User Guide, CMS has exempted its Medicare Secondary Payer Reporting processes from exclusive use of the MBI. Consequently, we can continue to report to CMS using a Social Security Number, a HICN or an MBI. In announcing this policy, CMS indicates it has renamed fields labeled “HICN” to “Medicare ID.”
While allowing for continued reporting of HICNs in its Section 111 reporting processes, CMS states that if an MBI has been issued to the claimant, it will return the MBI in the Section 111 response files. We expect then that while not requiring submission of MBIs, CMS nonetheless expects a natural transition to their use for MSP matters over time.
Medicare Conditional Payment Recovery Correspondence to Include Either HICN or MBI
As part of this update, CMS states that its recovery contractors, the Benefits Coordination and Recovery Center (BCRC) and the Commercial Repayment Center (CRC), will use either an HICN or MBI in its correspondence based upon the most recent information provided by the Responsible Reporting Entity (RRE) when creating or updating the MSP record. Again, we expect a natural transition from use of HICNs to MBIs in correspondence from the recovery contractors over the next few years.
The Tower MSP Automation Suite is fully capable of accepting SSNs, HICNs or MBIs for purposes of Section 111 Mandatory Insurer Reporting.
ORM Termination Defined
In addition to updating its User Guide to address the transition to MBIs, CMS also added language to its Section 111 “Policy Guidance” User Guide specifically defining under what circumstances Ongoing Responsibility for Medical (ORM) may be terminated. The revised Section 6.3.2 states as follows:
6.3.2 ORM Termination
When ORM ends, the RRE should report the date that ORM terminated and should NOT delete the record. Please note that a TPOC amount is not required to report an ORM termination date. An ORM termination date should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. An ORM termination date should only be submitted if one of the following criteria has been met:
While now formalized, this ORM termination guidance had previously been provided by CMS, either in other sections of the User Guide or in guidance provided outside the guide, such as through CMS Townhall calls.
Notably, advocacy efforts have been made with CMS to request an expansion of the ORM termination criteria. Such expansion would, for example, provide for ORM termination if no medical has been paid on a claim over a certain number of years. The benefit of allowing for a greater number of claims to terminate ORM would be less of an administrative burden for employers and carriers and a reduction in denials of payment by Medicare for charges completely unrelated to reported claims.
Unfortunately, CMS has thus far been unresponsive to expanding its definition of ORM termination, choosing instead to work out improper denial of payments and unwarranted conditional payment recovery efforts on the back-end rather than addressing the quality of the data reported to CMS on the front-end.
The Updated Section 111 User Guide, Version 5.3, may be found here.
Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with any questions regarding the updated guide.
December 27, 2017
In a recent post on its website, the Centers for Medicare and Medicaid Services (CMS) acknowledged the opioid crisis in this country, but provided little clarity as to how it intends to address this crisis in its review and approval of Workers’ Compensation Medicare Set-Asides (WCMSAs).
The 12/14/2017 statement provides as follows:
CMS understands the concerns regarding the opioid crisis occurring in the United States. We are committed to ensuring the determination of Workers’ Compensation Medicare Set Aside Arrangement (WCMSA) amounts are an adequate projection of claimant’s needs for future medical services and prescription drugs. CMS continually evaluates all policies and procedures related to WCMSA amounts. Any changes that Medicare pursues related to this issue will be reflected in our WCMSA amount review process.
More information on the WCMSA process can be found in the WCMSA Reference Guide.
We assume the above statement may be, in part, related to the California Workers Compensation Institute (CWCI) study finding nearly 70% of CMS approved MSAs require funding of opioids over an injured worker’s life expectancy (See our article, Opioids in the MSA . . . Challenges and Strategies, where this study is discussed). While we credit CMS’s Office of Financial Management (the CMS department which oversees the WCMSA review program and contractor) with recognizing the opioid crisis, what is left uncertain is what specific actions CMS is to take to address this problem in WCMSAs. Instead, CMS provides a vague statement indicating any changes related to the opioid issue will be reflected in its WCMSA review process and then cites its WCMSA Reference Guide.
CMS does not cite to a particular section of the guide, but we assume the following would be the most pertinent:
Drug Weaning/Tapering
Drug weaning commonly occurs with pain medications, such as opioids, especially when claimants’ work injuries improve. The WCRC takes all evidence of drug weaning into account, although in most circumstances the WCRC cannot assume that the weaning process will be successful. Usually, the latest weaned dosage is extrapolated for the life expectancy, but again, they assess all records when making these types of determinations. Where a treating physician believes tapering is possible and in the best interests of the claimant, CMS will consider all evidence in making a WCMSA determination, including medical evidence of current actual tapering.
Based upon the Tower MSA CMS Reconciliation Module, which reviews all MSA determinations for the purpose of identifying trends in CMS WCMSA allocation practices, CMS consistently disregards any active weaning or tapering process or scheduled reduction to future medication use and instead takes the latest dosage found in the medical records and/or prescription history and extrapolates it over the claimant’s life expectancy.
The question then is whether this December 2017 statement signals a departure by CMS from these past practices to a policy which will now give more weight to a weaning or tapering schedule from the treating physician which translates into limitations on the allocation of opioids in the WCMSA. We will take a wait and see approach in this regard.
It should be understood though that even were CMS to limit the allocation of opioids in the WCMSA, this in no way prevents the claimant from using the WCMSA funds for filling opioid prescriptions in excess of what is allocated. The reason being is CMS rules for administering a WCMSA allow for the funds in the account to be used for any Medicare-covered injury-related treatment or medication. As such, with a valid prescription, there is nothing to stop a claimant from converting funds allocated to a surgery to pay for medications, including opioids. It will remain then in the hands of the claimant’s medical provider to wean the claimant off opioids and other medications not intended for long-term use.
Practical Implications
As always, we will monitor CMS WCMSA determinations for signs of any changes to their allocating practices for prescription medications, especially in regard to opioids. However, we have to assume that until we see any changes, CMS will continue to follow its policy of taking the most recent medication dosage and frequency and pricing it out over the claimant’s life expectancy.
What this means then is opioid misuse must be addressed prior to submission of a WCMSA to CMS with any actual elimination of opioids documented in the medical records prior to submission of the MSA. Tower MSA is committed to working with our clients on reduction and elimination of opioids prior to CMS submission. Our Pre-MSA triage service is uniquely designed to identify such MSA cost-drivers and recommend intervention strategies, including escalating the matter to our Internal Pharm. D. for direct contact with the treating physician. Resulting reductions in opioid use limit MSA costs to the employer and provide for a healthier injured worker over his or her lifetime.
Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with any questions regarding CMS practices in allocation of prescription medications in the WCMSA.
December 19, 2017
As 2017 winds down, it seems like an appropriate time to feature some of the top content that has been provided by Leaders from the industry for our Leaders Speak section.
So, as we close out the year and prep to bring you more great thought leadership in 2017, check out the list below for our most popular Leaders Speak posts from the first half of this year (in no particular order)…
The full article may be found here.
December 6, 2017
“I start to think we are making progress and we are getting somewhere and opioid use in comp is down, and then you come across something like this,” said Alex Swedlow, president of the Oakland-based California Workers’ Compensation Institute, which conducted a study that found 70% of federally mandated and approved California workers compensation Medicare set-aside settlements for injured workers include money earmarked for decades of opioid use.
“It’s a confirmation of what we believe has existed,” said Rita Wilson, CEO and co-founder of Delray Beach, Florida-based Tower MSA Partners L.L.C., which helps insurers and employers remain Medicare-compliant and began tackling the opioids in Medicare set-asides in mid-2015. “(It) quantifies the concern of too much opioids in the Medicare set-asides,” she said of the study that was released in the fall.
The full article may be found here.
It’s the week of our industry’s biggest conference of the year. There will be a lot of great content, but be sure not to miss these 5 sessions:
The full article may be found here.
November 3, 2017
If seeing the word opioids one more time doesn’t trigger some sort of reaction, whether sadness, anger, desperation, or possibly hope at what appears to be traction to ‘Turn the Tide’ of addiction, then I can only surmise that you must live under a rock! That certainly isn’t the case here, as in our world of MSP compliance, the word opioids is either read, spoken or written every single day. It permeates our industry and our lives.
The most recent example of the profound impact opioids continue to have on workers’ compensation, the MSP industry, and specifically on the Medicare Set Aside (MSA), came from a study released earlier this week by the California Workers’ Compensation Institute (http://www.cwci.org). Those who saw the study became painfully aware that in the state of California,
“Nearly 70% of federally mandated and approved Medicare settlements for injured workers require funding for decades of opioid use, often at dangerously high levels and in conjunction with other high-risk drugs.”
The CWCI examined data from 7,926 California WCMSA plans completed, submitted and approved by the Centers for Medicare and Medicaid Services (CMS) in 2015 and 2016. To achieve a representative cross section of the state’s MSA cases, the authors compiled its dataset of 7,926 WCMSAs from four national vendors whose work product represented more than 50% of the state’s MSA market.
Overall findings were as follows:
Also significant were CWCI’s findings when the authors compared opioids found in WCMSAs to a case-matched control group of closed workers’ comp permanent disability claims for similar injuries. This comparison demonstrated that the WCMSA allocations included much stronger opioids, with average morphine milligram equivalents (MMEs) at 45 times the level used in the control group during the life of the claim. In addition, the WCMSAs with opioids required funding for an average daily dose of 54.7 morphine equivalents (MEDs) for a period of 20.9 years.
The realization that opioids represent a major problem with the WCMSA did not come as a surprise to Tower, or to the National Alliance of MSA Professionals (NAMSAP). For the past 2 years, NAMSAP, through its Evidence Based Medicine and Data and Development committees, has been working tirelessly to educate the MSP community as to what happens in the MSA when opioids are prescribed over the life of the claim and remain as standard treatment when the MSA is prepared and submitted to CMS. NAMSAP has hosted multiple webinars to bring industry, regulatory and legislative experts together to discuss the opioid impact, and sent representatives to Washington to discuss our concerns with CMS. At our most recent annual conference, NAMSAP hosted Assistant Surgeon General, RADM Pamela Schweitzer, Pharm.D., BCACP, who shared both her concern for our situation, and her enthusiasm for our passion and our efforts.
With a singular focus among our members, I am hopeful that NAMSAP can successfully modify prescribing behavior and ultimately impact WCMSA outcomes. Unfortunately, this doesn’t benefit carriers, employers, third party administrators and injured workers today.
At Tower, the issue of opioid misuse and the importance of pre-MSA intervention has been in the forefront of our business model, our technology platform and our workflow from day 1. Our Pre-MSA Triage service identifies issues long before the MSA and provides practical recommendations to address obstacles. Our integrated technology platform tracks pharmacy triggers and interventions, escalates to our Internal Pharm. D. to contact the treating physician and diaries to track progress until treatment has been optimized. We then finalize the MSA and submit to CMS for approval.
The result of our workflow, our technology and the internal team of clinical, legal and medical experts we’ve built is a streamlined, end-to-end process that identifies issues, tracks progress and drives results for our clients.
Results achieved across all clients:
These are numbers we track monthly through our CMS Reconciliation Module to confirm that CMS performance continues to improve. Our belief is that until prescribing habits change and best practices in opioid treatment can be implemented and enforced, our responsibility is to drive better outcomes through both formal intervention services and consultative oversight. Our clear focus is to limit pharmacy to those medications that are appropriate for long term use, to discontinue opioids where possible and to reduce MED to the lowest level possible when opioids must be included in the WCMSA.
In the words of HHS Secretary, Tom Price, M.D. and Kellyanne Conway, counselor to President Trump,
“Ending the opioid epidemic will require an all hands on deck effort”.
Stay tuned.
