News Archives

CMS Releases Statement Regarding Stakeholder Input in Liability MSA Review Process

October 27, 2017

CMS issued the following brief statement on their website this week:

The Centers for Medicare and Medicaid Services (CMS) continues to consider expanding its voluntary Medicare Set-Aside Arrangements (MSA) review process to include liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS will work closely with the stakeholder community to identify how best to implement this potential expansion of voluntary MSA reviews. Please continue to monitor this website for updates and announcements of town hall meetings in the near future.

Notably, very little information provided other than stating CMS will work with stakeholders before formalizing the expansion of the MSA review process to liability and no-fault. Based upon this statement, we can assume CMS will not spring the expansion on us, but give impacted parties an opportunity to comment before a final policy is put in place. Tower MSA will provide updates when further information is released by CMS or town hall meetings are scheduled.

Don’t Plan to Fail: Best Practices for Addressing Medicare Advantage Plan Reimbursement

October 25, 2017

Benjamin Franklin must have been contemplating Medicare Advantage Plan reimbursement when he uttered one of his famous lines: “If you fail to plan, you are planning to fail.” Over the past few years Medicare Advantage plans have increasingly been seeking reimbursement for payments made stemming from workers’ compensation, liability and no-fault claims, otherwise known in Medicare circles as Non-Group Health Plans (NGHPs). Despite these increasing efforts, many NGHPs have not planned how they should respond to such reimbursement claims.

With the goal of working with our clients to educate and assist with proper planning, earlier this month, Tower MSA was privileged to have Brian Bargender, Subrogation & Other Payer Liability Business Consultant for Humana, participate in a webinar to discuss reimbursement rights of Medicare Advantage plans, and best practices for investigating and responding to reimbursement claims. For those who were unable to attend, or would like a refresher, we are pleased to provide below a summary of Mr. Bargender’s presentation along with some final thoughts and takeaways.

Medicare Advantage Plan Background

Part C Medicare Advantage plans (MA plans) are alternative delivery mechanisms for traditional Medicare benefits (Parts A and B) provided by private companies under contract with CMS. Medicare beneficiaries have the option of choosing one of these Medicare Advantage plans during annual or special enrollments periods. The three largest MA plan sponsors (representing almost half of the available plans) are UnitedHealthcare, Humana and Aetna. As of 2017, one-third of Medicare beneficiaries are enrolled in MA plans.

Medicare Advantage Plan Recovery Rights

Pursuant to CMS direction, MA plans must enforce the Medicare Secondary Payer Act (MSP) and will be audited by CMS for compliance with the Act. Consequently, these plans are obligated to coordinate benefits such that MA Plan coverage is denied when a primary payer is covering treatment and when the MA plan pays, but later learns of primary payer responsibility, seek reimbursement for payments made relating to the particular workers’ compensation, liability or no-fault claim.

MA plans right to reimbursement, including double damages, from NGHPs under the MSP Act has been acknowledged in at least two significant federal appellate court decisions:

In re: Avandia, 685 F.3d 353 (3d Cir. 2012)
Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229 (11th Cir. 2016)

Medicare Advantage Plan MSP Enforcement Challenges

Despite CMS’s direction to MA plans regarding enforcement of the MSP Act, including coordination of benefits, the data available to the MA plans to perform this task is inconsistent and error prone. Consequently, MA plans have taken one of three approaches to MSP enforcement:

Inactive: Minimal effort
Reactive: Relying upon member and medical provider reporting of primary plans
Proactive: Claim screening and investigation

As Mr. Bargender explained, Humana is taking the proactive approach. Nonetheless, the challenges faced by Humana in identifying coordination of benefits situations has proven difficult as a result of gaps in medical provider and Medicare beneficiary self-reporting and data provided by CMS which is “too little, too late, often wrong.” Additional challenges faced by MA plans are incomplete direction from CMS and non-cooperation of Medicare beneficiaries and plaintiff attorneys to MA plan reimbursement claims. As such, Humana utilizes a multi-faceted approach of member questionnaires, public records, such as accident reports and workers’ compensation claims, and non-public records, such as data relayed by CMS, to determine possible MSP coordination of benefits and reimbursement opportunities.

Best Practices for Non-Group Health Plans and MA Plan Reimbursement

Humana’s proactive approach then has the ultimate goal of reimbursement for charges related to the claimed injury. Mr. Bargender shared the following basic precautions to be taken by NGHPs:

Train front-line staff on MSP basics – including MA & Part D
Assume older & disabled claimants have some form of Medicare
Be proactive when told claimants don’t have original Medicare
Watch for other payer info in medical records
Watch for notices from other payers
No-fault and accepted work-comp claims
Pay treating providers directly for outstanding medical bills
Be suspicious of billing gaps (other payer?)

And when it comes to Liability and disputed or denied workers’ compensation claims:

Find out who paid for medicals

Providers rarely wait for settlements
CMS “no payment” letters aren’t the last word
Request benefit ID card(s)
Ask to see other payer “no payment” letters
Medicare/Medicaid dual beneficiaries? …assume Part D paid Rx

Address MSP repayment before agreeing to settlement

Determine amount before settlement is finalized
Don’t assume plaintiff will reimburse MA plan or unpaid providers
What does settlement indemnification language actually accomplish?

In terms of negotiating and resolving MA plan claims for reimbursement, Mr. Bargender offered as follows:

Most MA plans are open to working with primary payers

Focus on these:

Rationale for denying beneficiary’s underlying claim, not MA/Part D rights
Limits exhausted, treatment not allowed/capped, etc.
What’s related (was it in the demand or release?)
Errors in plan’s payment ledger
Extenuating circumstances

Not on these:

Reasonableness of amounts paid by MA
Claim filing time limits vs. MSP statute of limitations
Contract language” in the MA Evidence of Coverage document

Final Thoughts and Takeaways

In working with Mr. Bargender and the subrogation team at Humana, we have found them very helpful in promptly identifying specific reimbursement claim information where the claimant was enrolled in a Humana Medicare Advantage plan. Further, they are open to understanding the particular liability issues and bases for settlement, something not typically found with the Medicare conditional payment recovery contractors.

The primary takeaway from Mr. Bargender’s presentation is NGHPs must be proactive in identifying whether a Medicare eligible claimant is enrolled in a MA plan, and, if so, investigate whether the plan is seeking reimbursement for payments made related to the claim. As there exists no central database accessible to NGHPs in which to identify the MA plan a claimant is enrolled, the claims handler must be proactive in inquiring of the claimant whether they are enrolled in such a plan.

Tower MSA Partners will work with our clients to assist in identifying whether a claimant may be enrolled in a MA plan, identify the name of the plan and investigate whether such plan is seeking reimbursement stemming from the claim. We stand ready to assist you through general consultation on ensuring your MSP compliance program appropriately addresses MA plans or consultation on MA plan recovery* in a specific claim.

*While we did not delve into Part D Prescription Drug plans in this article, such plans arguably have similar reimbursement rights as Part C Medicare Advantage plans. NGHPs should also be aware of the potential for reimbursement claims from these plans.
Daniel Anders

Dan Anders, Tower’s Chief Compliance Officer, interviewed by WorkCompCentral to Discuss CMS’s Move To New Partner for NGHP Medicare Recovery

October 11, 2017

The Centers for Medicare and Medicaid Services has chosen Performant Financial Corp. as its Commercial Repayment Center contractor to replace CGI Federal.

The announcement of a new CRC contractor comes after CMS said in an August report that the CRC had recovered $106 million in fiscal year 2016 out of $244 million in payments identified as owed to Medicare. The amount was a decrease from $150 million recovered in fiscal year 2015 despite the expanded pool of payers for CRC to pursue.

Daniel Anders, chief compliance officer for Tower MSA Partners, compared the non-group recovery amount to the billions of dollars spent each year on workers’ comp medical benefits.

“When you consider that the CRC’s authority to recover on behalf of Medicare encompasses all non-group health plans who have accepted responsibility for injury-related medicals, $6 million seems fairly small,” Anders said on Tuesday.

The full article may be found here.

New Commercial Repayment Center Contractor on the Horizon; WCRC Contract Protested

October 9, 2017

A recent press release from the Performant Financial Corporation announced it has been awarded the Commercial Repayment Center (CRC) contract by the Centers for Medicare and Medicaid Services (CMS). Barring a bid protest, we expect a transition to the new CRC contractor over the next few months (CGI Federal’s contract, the outgoing CRC contractor, appears to run through 1/8/2018).

CRC Responsibilities

The Commercial Repayment Center is responsible for identifying and recovering primary payments mistakenly made by the Medicare program when another entity had primary payment responsibility (otherwise known as conditional payments). While CGI Federal has had the responsibility for recovering from group health plans for several years, it has been recovering from non-group health plans, such as a liability insurer, no-fault insurer, or workers’ compensation entity, only since 10/1/2015.

As those of you who have had any dealing with the CRC know, communication with the CRC following that start date was often frustrating as a result of long turnaround times to receive conditional payment information and inconsistent and contradictory responses from CRC representatives. While communication with the CRC has definitely improved over time, CMS has nonetheless chosen not to renew their contract with CGI Federal. CMS’s reasons are unstated, but as we noted in a recent article, CMS Releases Annual Report on CRC Conditional Payment Recovery, conditional payment amounts recovered by the CRC on behalf of Medicare declined from 2015 to 2016, despite the expansion of CRC’s recovery efforts to non-group health plans.

Besides the CRC contract, Performant currently acts as a Recovery Audit Contractor (RAC) for Medicare’s fee-for-service program (Parts A and B). As a RAC, Performant identifies and corrects improper payments made to medical providers as a result of insufficient documentation to support the payment, payments made which do not meet CMS guidelines and payments made for services that are incorrectly coded.

Similar to the RAC contract, the CRC contract is paid on a contingency basis. Consequently, the CRC contractor has an incentive to recover as much as possible on behalf of CMS. Per the Performant press release, “at full scale, Performant anticipates staffing the program with over 250 dedicated employees operating out of Performant’s offices around the country.”

CMS contractor transitions (see below bid protest) usually do not go as smoothly as advertised, thus we will wait and see how effectively this new contractor takes on the role as the CRC. We will advise you of any important developments during to and subsequent to the contractor transition.

WCRC Contract Under Protest

In a 9/11/2017 article, CMS to Transition to New MSA Review Contractor, we detailed the awarding of the new $60 million, five-year contract, for the Workers Compensation Review Center (WCRC) to Capitol Bridge, LLC. Two of the unsuccessful bidders, Arch Systems, and Ken Consulting, have filed formal protests to the awarding of the contract to Capitol Bridge. The protests are to be resolved by 12/21/2017. It appears then that this will delay the transition to the new WCRC. We will keep you apprised of any notable news on the WCRC transition.

Tower MSA Partners Rita Wilson and Dan Anders to Speak at NAMSAP Annual Conference

September 21, 2017

The NAMSAP Annual Conference – MSP Policy Palooza 2017 – takes place September 27-29 in Baltimore.

Tower MSA Partners’ CEO Rita Wilson and Chief Compliance Officer Daniel Anders, MSCC will participate in two sessions at the National Alliance of Medicare Set Asides Professionals (NAMSAP) Annual Conference this month.

New rules, new contractors, new risks, and the ever-changing healthcare landscape keep the Medicare Secondary Payer (MSP) industry in constant flux. Where is it heading and how can MSP companies guide clients through changes? Wilson will join Gary Patureau, of the Louisiana Association of Self Insured Employers (LASIE), Optum’s Lavonya Chapman, and Sedgwick’s Michael Merlino to examine trends and prognosticate about the future. “MSP Predictions” will start at 10:45 a.m. on September 29.

“With a new Workers’ Compensation Review Contractor (WCRC), a new WCMSA re-review announcement and the potential for changes with Liability MSAs, payers need MSP guidance now more than ever,” Wilson said. “Presented from the payers’ perspective, this session will focus on the challenges of the current environment, future predictions and a ‘call to action’ for the MSP industry to drive future behaviors.”

Anders and Contact Claims Services’ Jeff Knipper will present the “Alignment of MSP Processes” on September 27 at 4:30 p.m. This session explores the connection among Section 111 reporting, conditional payments and MSAs.

“Traditionally the industry has viewed these as separate activities and kept them in silos,” Anders said. “But each impacts the other and you need a continuous, cohesive process to accurately manage every aspect.”

The NAMSAP Annual Conference – MSP Policy Palooza2017 – will be held at the Renaissance Baltimore Harborplace Hotel September 27-29, 2017.

For more information on the conference, see:

NAMPSAP 2017 Annual Educational Conference

For more information on the Tower MSA Partners presenters, see:

Tower MSA to Host Free Webinar on Medicare Advantage, Part D Plan Recovery Recovery Rights

September 14, 2017

Tower MSA Partners will host a free webinar on Medicare Advantage and Part D Plan Recovery Rights on October 4 at 12:00 PM EDT. Tower MSA Partners is pleased to have Brian Bargender, of Humana, as the guest presenter for the Webinar. Humana is the second largest Medicare Advantage Plan and Part D plan in the country and has been the leading advocate for seeking reimbursement under the MSP Act from primary payers and Medicare beneficiaries for payments made through these plans.

Areas covered in the presentation are:

Intro to Medicare Advantage and Part D Plans
MSP guidance provided by CMS to MA and Part D Plans
MA and Part D MSP enforcement rights
Obstacles to enforcing MSP
Tips for addressing MSP with MA and Part D plans

To register for the Tower MSA Premier Webinar, click here.

To read more about the Webinar, click here to read article posted on WorkersCompCentral about the Webinar.

CMS to Transition to New MSA Review Contractor

September 11, 2017

On September 1, 2017, the Centers for Medicare and Medicaid Services (CMS) announced the awarding of the contract for the Workers Compensation Review Contractor (WCRC) to Capitol Bridge, LLC. The $60 million contract is for one-year with the option of renewing for an additional four years.

Since 2003, CMS has had in place the WCRC for the purpose of reviewing Workers’ Compensation Medicare Set-Aside (WCMSA) proposals submitted to CMS for review and approval. The WCRC evaluates these proposals and provides a recommendation 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 proposed MSA.

Provider Resources, Inc., has been the WCRC for the past five years. It is unclear based upon the available information when Capitol Bridge will take over from Provider Resources, although the solicitation for the WCRC contract provided for a three-month transition period.

Tower MSA Takeaways

It is important to note that while the review contractor may change, the policies in place to review WCMSAs are set by CMS, not the contractor. Consequently, we do not anticipate any significant change to how WCMSAs are reviewed and approved under the new contractor. Nonetheless, there are some recent changes to the WCMSA Reference Guide, such as the Amended Review process, which will fall largely on Capitol Bridge to implement (See article: Practical Implications of the Revised CMS WCMSA Reference Guide). Also, as we advised in another article, CMS MSA Review Expansion to Liability Planned for 2018, the new WCRC contract provides for an optional expansion of the WCMSA review process to liability claims as of 7/1/2018. At this time, it is uncertain whether CMS will choose to move forward with such an expansion as of that date.

Given our experience with other CMS contractor transitions we anticipate the new contractor will have a learning curve, which may result in longer turnaround times for MSA submissions and some responses inconsistent with the prior contractor’s reviews. Tower MSA will, if necessary, address with CMS any WCMSA approval falling outside of established CMS guidelines.

We look forward to working with Capitol Bridge over the coming months and years to provide for an effective WCMSA review and approval process that benefits all interested parties. Tower MSA will continue to provide any relevant updates as Capitol Bridge transitions to its role as the WCRC.

Statement Regarding Hurricane Irma’s Impact on Tower MSA Partners Services

September 8, 2017

As the safety of Tower MSA Partners employees and their families is our utmost concern, Tower MSA’s office in Delray Beach, FL, may be closed on Monday, September 11, 2017, and longer depending upon the impact of Hurricane Irma on South Florida. In anticipation of this closure, we have implemented our business continuity plan which provides for our continued full service to our customers from locations outside of the storm’s path.

With server location for all of Tower’s systems in redundant facilities across the U.S. and relocating Tower staff to multiple backup facilities, business operations will function as normal. All phone inquiries and referrals should be directed to (888) 331-4941 and e-mail inquiries and referrals to referrals@towermsa.com. It is possible that you may experience a slight delay in response, but be assured your request will be handled expeditiously.

For urgent requests, additional contacts are as follows:

1. Compliance questions regarding conditional payments, MSAs and CMS submissions may be directed to Dan Anders, Chief Compliance Officer, at 847-946-2880.

2. Section 111 questions may be directed to Hany Abdelsayed, EVP of Strategic Services, at 916-818-8062.

3. Clinical MSA questions may be directed to Patricia Smith, EVP of Clinical Operations, at 321-320-1045.

We will continue to communicate post-Irma and advise all once we return to normal operations in our Delray office.

Thank you for your understanding and, most importantly, our thoughts and prayers to those who have been affected and will be affected by this storm.

Rita Wilson
CEO
Tower MSA Partners

CMS Releases Annual Report on CRC Conditional Payment Recovery

September 5, 2017

On 8/30/2017 the Centers for Medicare and Medicaid Services released its annual report on the Commercial Repayment Center’s (CRC) Medicare conditional payment collections for the 2016 fiscal year (10/1/2015 through 9/30/2016). In short, the report documents the CRC identified $243.68 million in conditional payments, collected a net of $106.29 million and returned $88.35 million to the Medicare Trust Fund after subtracting collections costs.

The CRC, which is paid on a contingency basis, has responsibility for Medicare conditional payment recovery efforts involving Group Health Plans and Non-Group Health Plans (NGHP). NGHPs are liability insurance (including self-insurance, no-fault insurance or workers’ compensation). FY 2016 was the first fiscal year in which the CRC had responsibility for recovery of conditional payments from NGHPs, a task previously handled by the Benefits Coordination and Recovery Center (BCRC). Recovery claims involving Medicare beneficiaries remain with the BCRC.

A copy of the report may be found on the CMS website here.

Some observations from the report:

CMS does not split out GHP and NGHP recovery information which makes it difficult to ascertain, one, the effect of adding NGHPs to the CRC’s responsibility has had on overall collections and, two, the percentage of overall collections attributable to GHPs versus NGHPs.
Despite identifying $243.68 million on conditional payments, the CRC only recovered $117.40 million, shortly under half (48%) of the identified amounts. This may be the result of the provided data only documenting debts that are identified and collected within the fiscal year. The report indicates that collection of FY 2016 identified debts continues into the next fiscal year.
Connected to the above observation, it is disappointing that the CRC does not provide a more comprehensive multi-year view of its recovery work. Information such as amounts recovered over the past several years, average turnaround time from demand to repayment, and the above-mentioned GHP vs. NGHP data would be invaluable to understanding the overall program.
Provided in the report is a statement indicating amounts returned to the Medicare Trust Fund dropped from $125.05 million in FY 2015 to $88.35 million in FY 2016. CMS attributes the drop to “a decrease in GHP recoveries due in part to the maturity of the mandatory insurer reporting under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 decreasing the instances of mistaken payments, as well as the CRC’s resolution of pending available recoveries.” This drop is nonetheless surprising given that FY 2016 marked the CRC’s first year recovering from NGHPs!

Takeaways

We do not recommend any changes to your Medicare conditional payment resolution program or process based upon the report. The report merely provides a window into the efforts by the CRC at recovering conditional payments from GHPs and NGHPs.

Practical Implications of the Revised CMS WCMSA Reference Guide

August 18, 2017

Earlier this month the Centers for Medicare and Medicaid Services (CMS) released a revised Workers’ Compensation MSA Reference Guide (WCMSA) (find Version 2.6 here) with several notable changes and additions impacting its review of MSAs in workers’ compensation cases. The Tower MSA compliance team has taken some time to review and consider not only the substantive impact these changes have on our processes, but the implications for our clients. Please find below a summary of the notable changes to the Reference Guide along with practical implications.

Recognition of a Hearing on the Merits of the Case (Section 4.1.4)

The relevant change to this section is as follows:

Because the CMS prices based upon what is claimed, released, or released in effect, the CMS must have documentation as to why disputed cases settle future medical costs for less than the recommended pricing. As a result, when a state WC judge or other binding party approves a WC settlement after a hearing on the merits, Medicare generally will accept the terms of the settlement, unless the settlement does not adequately address Medicare’s interests. This shall include all denied liability cases, whether in part or in full . . .

Practical Implications

Over the years CMS has had several definitions of under what circumstances it will recognize a hearing on the merits, but the takeaway has consistently been that CMS gives itself complete discretion as to whether or not it will recognize a particular judicial decision, order or finding as limiting the MSA. Some commentary in response to the Reference Guide revisions has indicated the changes found in this section will result in Zero MSAs based upon a complete claim denial no longer being approved without a hearing on the merits confirming the basis for the denial. We are not certain this is the correct inference to draw from this change. This section addresses the effect of a hearing on the merits of a case to the projection of future medical care. If there is no hearing on the merits of the case, which is the situation in most MSA submission, Zero MSA or otherwise, then this section should have no applicability to CMS’s review of a Zero MSA.

Tower MSA’s plan is to stay the course on the long-used criteria for a Zero MSA based upon a claim denial unless and until we identify any changes through the MSA submission process which requires modification to these criteria.

Recognition of State-Specific Statutes (Section 9.4.5)

The relevant change to this section as follows:

Submitters requesting alteration to pricing based upon state-legislated time limits must be able to show by finding from a court of competent jurisdiction, or appropriate state entity as assigned by law, that the specific WCMSA proposal does not meet the state’s list of exemptions to the legislative mandate. For those states where treatment is varied by some type of state-authorized utilization review board, the submitter shall include the alternative treatment plan showing what treatment has replaced the treatment in question from the beneficiary’s treating physician for those items deemed unnecessary by the utilization review board. Failure to include these items initially will result in pricing at the full life expectancy of the beneficiary or the original value of treatment without regard to the state utilization review board recommendation.

Practical Implications – State-Legislated Time Limits: Similar towards its policy on recognizing decisions stemming from hearings on the merits, CMS has consistently given itself complete discretion as to when it will recognize any state statute as providing a limitation on the medical care allocated in the MSA. Experience has shown CMS to be unwilling, under most circumstances, to recognize a state statute as having the affect of limiting medical care in the MSA. A notable example is the Georgia statutory provision limiting an employer’s responsibility for medical care to 400 weeks post the date of injury in non-catastrophic claims (applicable to cases with DOIs of 7/1/2013 and later). We have yet to see an instance where CMS has agreed to limit the MSA amount based upon this statute.

The changes to this section of the Reference Guide provide hope that CMS may be more open to recognizing state statutes, like Georgia’s, as a basis for limiting medical treatment and medications in the MSA. Unfortunately, the requirement “to show by a finding from a court of competent jurisdiction . . . that the specific WCMSA proposal does not meet the state’s list of exemptions to the legislative mandate” presents a challenge in attempting to use a statutory provision to limit the MSA. For example, in Georgia a workers’ compensation case is by default considered non-catastrophic unless accepted by the employer or carrier as catastrophic or the claimant’s attorney submits to the Georgia Workers’ Compensation Board a request for the claimant to be designated as catastrophic. It is unclear at this point whether confirming the non-catastrophic nature of the claim in board approved settlement documents or a separate finding by the board that the claim is non-catastrophic will be sufficient for CMS to recognize the limitation. Based upon our experience with similar types of issues, we expect CMS to require a specific finding separate and apart from the settlement documents. Accordingly, this will require settling parties, whether in Georgia or in other states, to work with their WC board, commission or other judicial authority to provide the necessary finding confirming the claim does not meet any of the exemptions to the statute.

Practical Implications – Utilization Reviews: Revisions to this section of the Reference Guide also address the use of URs to limit care in the MSA. According to the requirements delineated by CMS the following must be presented with the MSA submission:

UR denial pursuant “some type of state-authorized utilization review board.”
“Alternative treatment plan” from the treating physician showing what treatment has replaced the UR denied treatment or medications.

The addition of the language regarding URs raises more questions than it answers. What does CMS define as a UR Board? For example, the California Independent Medical Review (IMR) process, while statutorily created, does not include a UR review board (Although we believe it can be argued that the IMR process is equivalent to such a board). Further, CMS fails to define what would be considered an “alternative treatment plan.” It would seem that an intransigent treating physician could refuse to provide alternative treatment, thus resulting in inclusion of treatment or medications in the MSA denied through the UR process. It is unfortunate CMS added this “alternative treatment plan” requirement as it undermines the very reason a UR process is in place, namely to limit medical care based upon evidence-based treatment guidelines. As Tower MSA submits MSAs to CMS with UR denials we will provide further recommendations as to how CMS is defining a “UR board” and “alternative treatment plan.”

Addition of “Amended Review” to Re-Review Policy (Section 16.0)

As fully explained in the Tower MSA article of 7/12/2017, “Second Chance with MSA Approval!: New CMS Policy Allows for Review of a New MSA Post a Prior Approval,” CMS has introduced what is called an Amended Review process for cases meeting the following criteria:

Practical Implications: The Amended Review criteria presents an opportunity to have a second bite at the CMS MSA review apple when it comes to claims which despite having a previously approved MSA, failed to settle medical. It is important to note that the Amended Review process applies not only to MSA determinations resulting in counter-highers, but any MSA determination, approved as submitted or counter-lower, that meets the above-defined criteria. Please contact Tower MSA to discuss eligible claims.

Added Section on Required Resubmission (Section 16.1)

The addition to this section is as follows:

Where a proposed WCMSA amount has been closed due to inactivity for one year or more from the original date of submission, a full-file resubmission will be required.

Practical Implications: Previously a case closed for inactivity for one year or more would be reopened if the submitter provided the documentation in response to a Development Letter (The most common reason for case closure). CMS is now indicating solely providing the documentation in response to the Development Letter will be insufficient for them to reopen, instead a completely new MSA proposal and supporting documentation will be required. Tower MSA will advise when a case meets the criteria for filing a resubmission.

Additional MSA Administration Guidelines (Section 17.1)

The addition to this section is as follows:

Although beneficiaries may act as their own administrators, it is highly recommended that settlement recipients consider the use of a professional administrator for their funds.

Practical Implications: While not requiring professional administration, this is an acknowledgement by CMS of the difficulties a claimant may face on their own in administering an MSA. Tower MSA agrees with CMS on the benefits of professional administration and when requested by our client will provide MSA professional administration through our partner, Ametros.

Other less notable changes found in the Reference Guide apply to clarifying the order of jurisdictional precedence for MSA pricing, updating requirements for spinal cord stimulator pricing, updating off-label medication requirements, clarifying total settlement calculation guidelines and clarification of change of submitter requirements.

Final Comments: While we are pleased CMS is addressing the concerns expressed by Tower MSA and others in the MSP compliance field concerning a second chance at CMS review of an MSA and recognition of state statutory limitations on injury-related medical care, the real test will be in the coming weeks and months the affect these revisions have on the review of MSAs submitted to CMS for approval. Tower MSA continuously monitors these responses and will provide our clients appropriate guidance on the impact, or lack thereof, of these revisions and additions to the WCMSA Reference Guide.