Category: News

Federal Court Holds Against Medicare Practice of Over-Inclusive Reimbursement Demands

February 13, 2017

The California Insurance Guarantee Association (CIGA) has prevailed in its lawsuit (Cali. Ins. Guar. Ass’n v. Burwell, No. 2:15-cv-01113-ODW (FFMx), 2017 U.S. Dist. Ct. LEXIS 1681) against the Centers for Medicare and Medicaid Service (CMS) challenging the practice of over-inclusive reimbursement demands by CMS. As a consequence of this ruling from the U.S. District Court for the Central District of California, claimants and employers, have judicial support to dispute charges which contain mixed diagnosis codes, some related to the workers’ compensation injury and some unrelated, in CMS’s conditional payment demands.

A summary of CIGA’s challenge to CMS, CMS’s response to the claim and the Court’s decision is detailed below with a discussion on practical implications of the decision.

CIGA’s Claim Against Medicare

CIGA claimed that CMS’s practice of seeking reimbursement for the full amount of a medical charge despite the charge including mixed diagnosis codes, some related to the workers’ compensation injury and some unrelated, goes beyond CMS’s authority under the Medicare Secondary Payer Act.

By way of background, medical providers include ICD-10 diagnosis codes within billing records that are supposedly associated with the treatment provided. However, it is commonly known that medical providers, especially hospitals, may add any and all diagnoses for which a claimant reports a medical condition, even if such condition is not the subject of the treatment on the bill. For example, a claimant who has a low back injury and seeks treatment at a hospital for a cardiac condition may report on an intake form that he has ongoing low back pain. The hospital may list a low back diagnosis code on the medical bill even though the incurred medical treatment is solely related to the cardiac condition. This is not to say that there may also be situations where actual treatment was received for the work-related injury, but, even then, it may represent only a portion of the overall charge.

As evidence to support its claim, CIGA presented three examples of recovery demands with mixed diagnosis codes. In one demand the Medicare conditional payment charge included a diagnosis code connected to the work-related back and hip injury, but other diagnosis codes relating to diabetes, insulin use and bereavement. In these cases, CMS issued a formal demand letter seeking recovery for the complete charge for both related and unrelated conditions. CIGA disputed on the basis that the charges “did not fall ‘within the coverage of an insurance policy of the insolvent insurer’” under California law.

CMS’s Response

The Court rejected all of CMS defenses as detailed below.

CMS withdrawing the demand is not a sufficient basis to dismiss the case

At some point following the initiation of CIGA’s lawsuit CMS “recalculated” its demands resulting in CMS effectively withdrawing the demands that were the subject of this litigation. CMS claimed that as the demands were withdrawn the case should be dismissed. The court denied the dismissal noting “Indeed, given the timing of the withdrawals (i.e., immediately after a hearing in which the Court made clear that CMS’s practice would not withstand scrutiny), it seems obvious that this is simply a strategic maneuver designed to head off an adverse decision so that CMS can continue its practice in the future.”

CIGA identifying unrelated diagnosis codes is a sufficient basis to shift the burden to Medicare

CMS disputed CIGA’s assertion that identifying the non-work related diagnosis codes is sufficient to shift the burden to Medicare to prove otherwise. The Court disagreed and held that it is sufficient to shift the burden to Medicare to prover otherwise, and further, that CMS never challenged CIGA’s claims that the diagnosis codes were unrelated.

CMS’s claim that the term “item and service” refers to the charge and not the treatment is unsupported

The Medicare Secondary Payer Act provides “a primary plan . . . shall reimburse [Medicare] for any payment made . . . with respect to an item or service if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service.” CMS regulations (42 CFR 1003.101) further define item or service “Any item, device, medical supply or service provided to a patient which is listed in an itemized claim for program payment or a request for payment . . . .”

CMS asserted the definition of “item or service” for which they are able to recover under their regulations refers to whatever (and how many) medical treatment(s) a provider lumps into a single charge. Not surprisingly, the Court found nothing under the statue nor the intent of Congress in writing the MSP Act to substantiate that “item or service” refers to the listed charge from the medical provider, rather than one medical treatment whether billed as a group with other treatments or listed singly.

CMS is bound by state law in determining whether the WC employer or carrier has responsibility to reimburse Medicare

CMS next argued that it is not bound by state law as state law is preempted under the MSP Act (Preemption refers to the principle that between federal and state law federal law trumps state law). The Court cited with approval a prior federal appellate court decision, Caldera vs. Ins. Co. of the State of Pa. 716 F.3d 861 (5th Cir. 2013) which addressed the question of whether CMS’s ability to recover is limited in anyway by state law. In Caldera the Court found “responsibility to make payment with respect to an item or service is generally a matter of state law.” Accepting then that CMS is held to state law in its ability to recovery, the judge in the present matter went on to cite several California state court decisions finding that a compensation carrier is not responsible for making payment on treatment unrelated to the workers’ compensation injury.

CMS is not entitled to deference in its interpretation of the MSP Act and regulations

The court rejected CMS claim of deference to its interpretation of the MSP Act and regulations since the Court found such an interpretation of CMS’s regulations actually supports CIGA and, further, its arguments conflict with CMS’s own MSP Manual which provides for medical providers to be reimbursed partially by a primary plan and partially by Medicare if work-related medical treatment is provided concurrently with non-work-related treatment.

Court Finds the Real Reason CMS Calculates in this Manner

The Court holds, “At bottom, it is quite clear that the real reason CMS calculates reimbursement demands in the manner that it does is simply because it is too difficult to do otherwise, not because that is what is required (or even permitted) by any statute, regulation, or policy manual.” According to the Court then, CMS must attempt to apportion the charge between covered and non-covered services. It is possible, as the court indicates, that CMS may find apportioning the charge unreasonable. The court further notes that if the charge is apportioned, it takes no position on how CMS should do so in terms of pro rata reimbursement, etc.

Practical Implications of Decision

Whether it is Medicare conditional payment recovery or Workers’ Compensation MSAs, CMS regularly asserts that it is not bound by state law in determining items or service for which it may seek recovery or to be included in the MSA. Further, CMS operates under an assumption that the courts will defer to its interpretation of the MSP Act and relevant regulations. At least in the Medicare conditional payment context, this decision completely refutes such assumptions. This is a well written decision which along with the holding in Caldera (mentioned above), is significant in finding that state law places limits on the extent of MSP conditional payment recovery. We applaud CIGA’s pursuit of this decision.

It should be noted that this is a U.S. District Court decision, not an appellate decision, thus it has limited precedential value for other cases addressing this same issue. Nonetheless, along with the Caldera case, which is an appellate decision, we now have two decisions which limit Medicare recovery. It is unclear at this point whether CMS will appeal the decision to the 9th Circuit Court of Appeals. A decision at that level would provide precedential value for all states within the 9th Circuit and would be on par with the Caldera case which was an appellate decision of the 5th Circuit.

The court does leave a door open for CMS in that CMS can determine whether it is unreasonable to separate a charge between related and unrelated. It is assumed though that CMS would have to provide evidence to support why it cannot reasonably separate the charges.

Tower MSA will utilize this important decision to support disputes of mixed diagnosis code conditional payment charges on behalf of our clients. Whether CMS will agree remains uncertain as this is a lower court decision and the decision itself still gives CMS the ability to determine whether it is reasonable to remove unrelated portions of a charge and how the remaining work-related amount of the charge should be apportioned. Tower MSA will continue to keep you apprised of any developments in this area of Medicare conditional payment recovery.

WorkersCompensation.com: Tower MSA Partners’ Rita Wilson Predicts CMS Re-Review Changes Will Help Payers

January 27, 2017

Tower MSA Partners CEO, Rita Wilson, was recently interviewed by WorkersCompensation.com following her participation in a January 24, 2017 “State of MSP” webinar presented by the National Alliance of Medicare Set-Aside Professionals (NAMSAP).

Workerscompensation.com asked Rita to comment on CMS’s December 21, 2016 announcement regarding its plans to update its WCMSA re-review process in 2017. This includes expansion of the process to previously approved MSAs where there has been a substantial change in the claimant’s medical condition and the case has not settled (For details see Tower MSA blog on the announcement: CMS Announces Plans for 2017 Expansion of MSA Re-Review Process & New Policy Regarding URs in MSAs)

Rita’s comments to WorkersCompensation.com follow:

“CMS will need to establish the parameters for re-review and define ‘substantial changes.’ We expect costly procedures such as surgeries and spinal cord stimulators to be included,” Wilson said. “A WCMSA involving patients who have weaned off expensive polypharmacy regimens could also qualify.”

“Tower’s workflow and decision-tree software application identifies recommended, not-yet-performed procedures and intervenes to address inappropriate treatment prior to submitting an MSA,” Wilson said, “But this could be a game-changer for payers with CMS-approved MSAs that they were unable to settle.”

The full article may be found here.

Removal of SSN from Medicare IDs Detailed in CMS Open Door Forum

January 23, 2017

On January 17, 2017, the Centers for Medicare and Medicaid Services (CMS) held a Special Open Door Forum to detail how the Social Security Number Removal Initiative (SSNRI) impacts the Medicare Secondary Payer (MSP) community. CMS’s explanation is summarized below with Tower MSA’s thoughts on the practical implications of this change.

SSNRI Explained

Presently, Medicare beneficiaries are assigned a Healthcare Insurance Claim Number (HICN) which generally includes either their or their spouses Social Security Number (SSN) followed by a letter, commonly an A or B. For the purpose of reducing identify theft involving SSNs, the Medicare Access and CHIP Reauthorization Act of 2015 included a provision requiring CMS to remove SSNs from all Medicare cards by April 2019.

In accordance with the Act, CMS announced that starting in April 2018 it will begin to issue what will be called Medicare Beneficiary Identifiers (MBIs) to replace the HICNs currently in use. MBIs will be 11-alphanumeric characters in length with letters only in uppercase. The MBIs will be assigned to approximately 60 million current Medicare beneficiaries and 90 million deceased/archived Medicare beneficiaries. CMS targets completion of the assignment of MBIs by April 2019.

CMS advised there will be significant outreach to Medicare beneficiaries, medical providers, and other stakeholders, such as the Medicare Secondary Payer community, prior to implementation of this change.

CMS has a dedicated website regarding the SSNRI which may be found here.

SSNRI Impact on MSP Compliance

In regard to Medicare Secondary Payer compliance processes, the MSP compliance community currently exchanges data with CMS through Section 111 Mandatory Insurer Reporting, the Medicare Secondary Payer Recovery Portal (MSPRP) and the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP). CMS made the following statements concerning the SSNRI’s impact on this exchange of information:

• Fields presently identified as HICN will be retitled “Medicare ID.”
• As the HICN fields currently accept 11 characters there will be no expansion of these fields as a result of the implementation of MIBs.
• SSNs can continue to be used for querying whether a particular claimant is a Medicare beneficiary through the Section 111 Reporting process and for communication through the MSPRP and WCMSAP.
• Use of partial SSNs will continue to be permitted for querying Medicare eligibility.
• After April 2018 the CMS response to a Section 111 query will either provide the HICN or the MBI, depending upon whether the particular Medicare beneficiary has been issued an MBI.
• Outgoing documentation through the MSPRP or WCMSAP will include the HICN or MIB, depending upon what was most recently reported. For example, if an MSA is submitted to CMS for review through the WCMSAP and contains a HICN, then the response from CMS will include the HICN. On the other hand, if an MIB is submitted, then the CMS response will include the MIB.

Treasury Department to No Longer Include Medicare ID

Also announced during the forum is an impending change by the Treasury Department to no longer include the HICN (or the MIB when it becomes active) in its correspondence stemming from Medicare conditional payment recovery. Instead, the Treasury Department will only list the Case Recovery ID that has been assigned to the case by either the Benefits Coordination and Recovery Contractor (BCRC) or the Commercial Repayment Center (CRC). This change is expected to occur before the end of 2017.

Practical Implications

An important takeaway from CMS’s explanation of the SSNRI is that for MSP compliance purposes we can continue to use SSNs in communicating with CMS and its contractors. What we should recognize is that as of April 2018 besides SSNs, claimants may be providing MIBs rather than HICNs. Further, it should be recognized that the Section 111 query process may return an MIB, rather than an HICN, starting in April 2018.

Our Tower MSP Automation Suite will seamlessly transition to recognition and reporting of MBIs for Section 111 Reporting purposes starting in April 2019. We do recommend to our clients that they confirm their internal claims database will be fully capable of recognizing the MBIs when they become active for Medicare beneficiary claimants.

Finally, the Treasury Department’s removal of any Medicare beneficiary identifier from its conditional payment recovery correspondence may present some difficulty to workers’ compensation, liability and no-fault plans in identifying the particular claimant from which the demand stems. Tower MSA will work with our clients to address any uncertainty, but we also recommend to our clients that they work with us to actively resolve Medicare conditional payments on open and settling claims such that these demands never are referred to the Treasury Department.

If you have any questions regarding the SSNRI, please contact Tower MSA Partners Chief Compliance Officer, Dan Anders, at (847) 946-2880 or Daniel.anders@towermsa.com

CMS MSA Review Expansion to Liability Planned for 2018

January 4, 2017

We are not even a week into 2017, but already have news to share regarding Medicare’s planned expansion of its Workers’ Compensation MSA review process to liability in 2018. In its recently released Request for Proposal for the Workers Compensation Review Contractor (WCRC), the Centers for Medicare and Medicaid Services (CMS) includes an option allowing CMS to expand the responsibilities of the WCRC to review of Liability Medicare Set-Asides (LMSAs) and No-Fault Medicare Set-Asides (NFMSAs) effective July 1, 2018.

The CMS WCRC RFP Solicitation may be viewed here.

Background on CMS Review of MSAs

Since 2001 CMS has had in place an official voluntary review process for Worker’ Compensation Medicare Set-Asides (WCMSAs). A WCMSA, as CMS states, is a “financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury.” The purpose of the review then is “to independently price the future Medicare-covered medical services costs related to the WC injury, illness, and/or disease and to price the future Medicare covered prescription drug expenses related to the WC injury, illness and/or disease thereby taking Medicare’s payment interests appropriately into account.”

These WCMSA reviews were initially handled by the CMS Regional Offices spread throughout the country, but eventually transitioned to a centralized WCRC in 2005 (The CMS Regional Offices must still approve the review recommendation of the WCRC before it is released to the WCMSA submitter). CMS’s RFP solicitation for the new WCRC contract indicates the contract is to be awarded by June 30, 2017 with a contract term running for five years from July 1, 2017 to June 30, 2022.

Expectations for Liability MSA Reviews

Presently, CMS allows its 10 Regional Offices to accept voluntary requests for review of LMSAs at each office’s discretion. Some Regional Offices have consistently refused to review any LMSAs while other offices agree to review based upon criteria that seemingly changes over time and bears no indication that it is indeed the official policy of CMS. It appears then that just as it did in 2005 when CMS took the responsibility away from the Regional Offices for reviewing WCMSAs, CMS is now considering centralizing the process of reviewing LMSAs with a contractor, leaving the Regional Offices to only approve of the contractor’s recommendations.

Some may recall CMS launched a prior initiative to establish a formal policy for consideration of future medicals in liability settlements when it issued an Advanced Notice of Proposed Rulemaking in 2012. This initial effort was ultimately withdrawn by CMS in 2014. CMS’s new initiative began with this June 9, 2016 notice on the CMS website:

The Centers for Medicare and Medicaid Services (CMS) is considering expanding its voluntary Medicare Set-Aside Arrangements (MSA) amount review process to include the review of proposed liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS plans to work closely with the stakeholder community to identify how best to implement this potential expansion. CMS will provide future announcements of the proposal and expects to schedule town hall meetings later this year. Please continue to monitor CMS.gov for additional updates.

No town hall meetings were scheduled in 2016, however, based upon this RFP indicating LMSA reviews will not begin until at least July 1, 2018, CMS has given itself 18 months to develop and implement a formal LMSA review policy. In terms of how many liability settlements such a review process would impact, CMS seems uncertain. A Statement of Work attached to the RFP indicates “reviews could represent as much as 11,000 additional cases (based on all FY2015 NGHP demands), or as little as 800 additional cases annually, depending upon industry response.”

Tower MSA Takeaways

Over the past 15 years, starting with the formalized review of WCMSAs, continuing with the implementation of Section 111 Mandatory Insurer Reporting and recent stepped up efforts at denying injury-related medical care and recovery of conditional payments for medical care related to workers’ compensation, liability and no-fault claims, CMS has expanded its enforcement under the Medicare Secondary Payer Act. It is not surprising then that CMS’s next objective is formalizing a voluntary review process for LMSAs.

It has been our experience that when CMS does implement new policy and procedures it does take a deliberative approach evidenced by the at least 18-month timeframe signaled with this RFP to expand the MSA review process to liability and no-fault. Our expectation then is over the next 18 months or longer, CMS will provide additional announcements concerning the rules and procedures around expansion of the review process.

Tower MSA will be involved in these discussions and will keep you abreast of relevant developments. In the interim, there remain important obligations of parties to liability settlements and no-fault claims under the Medicare Secondary Payer Act. Rest assured that you can rely upon Tower MSA’s team of MSP compliance experts for consultation and expert guidance in liability and no-fault matters.

If you have any questions, please contact Tower MSA Partners, Chief Compliance Officer, Dan Anders, at (847) 946-2880 or daniel.anders@towermsa.com

Christmas Miracles Can Happen in Workers’ Compensation

December 23, 2016

For those of us who deal with MSAs, it’s all too common to see claims at settlement time that started out as basic and simple, then spiraled downward as a result of bad prescribing habits, increased drug use and opioid addiction.  We hope for a different ending, but can  miracles really happen?

Background

In late 2015, Tower completed a pharmacy project for a small employer in California.  In the course of the project, drug triggers were identified, physicians were contacted and claimants were challenged to settle or make changes in treatment.  As you might imagine, many of the physicians fought the request for change.  But through perseverance, and working in tandem with the client, we pushed forward.

The Story as Shared by our Client

Dear Hany,

A few weeks ago, I was looking over the  case for one of the California claimants and wanted to share the amazing results we have achieved with this gentleman.

This case involved a 26 year old man at time of injury. He sustained a minor back injury but was taking Hydrocodone, Testosterone, Celecoxib, Lyrica, Nortriptyline, Methocarbamol, and FENTANYL.  With the recommendations and assistance from the Tower MSA Partners team, as well as support from his wife, we were able to get him into a new treating physician who agreed with our goal. He was weaned off of the Fentanyl, Methocarbamol, testosterone, hydrocodone, and Celecoxib. He has even started an exercise program.  He is now both proud and happy to report how well he is doing.

The injured worker is now 51 years old and he sadly notes that he missed out on 25 years of his life and his children’s lives because he was so “drugged”.   On a positive note, however, his new treating physician has been wonderful to work with and we see only good things for this claimant.

On the financial side we have now realized a reduction in the monthly Rx spend from $1,200 per month down to $600.  The injured worker is now only taking Nortriptyline, Lyrica and Celebrex and we expect to reduce reserves next year and approach him for a settlement in June, 2018.  None of this would have been possible if not for the Rx project and your team’s expertise, guidance and follow up assistance.

While we have had great success with many of the claims that we partnered on, this particular claim was really about improving his quality of life.  So please share my THANK YOU and gratitude with your team. Let them know that what they do can save a life and that is priceless.

It’s True….Miracles Can Happen in Workers’ Compensation

What a wonderful way to end the day and begin our holiday celebrations!

From all of us at Tower MSA Partners, our best wishes for a wonderful holiday, and a safe and prosperous 2017!

CMS Announces Plans for 2017 Expansion of MSA Re-Review Process & New Policy Regarding URs in MSAs

December 22, 2016

Employers, carriers and claimants frustrated by the inability to obtain a revised CMS MSA approval after a substantial change in the claimant’s pre-settlement medical condition may find relief from CMS in 2017. Also in 2017, CMS will be issuing a policy regarding use of utilization reviews in MSA submissions. These potentially significant improvements in the CMS MSA review process are provided in a 12/21/2016 “teaser type” announcement on CMS’s website which states:

The Centers for Medicare & Medicaid Services recently revisited the task of reviewing its process for addressing requests for CMS to “re-review” otherwise approved Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) amounts. In Calendar year 2017, CMS expects to update its existing re-review process to address situations where CMS has provided an approved amount, but settlement has not occurred and the medical care that supported the approved amount has changed substantially. CMS also expects its updated process to address situations where certain states rely on Utilization Review Processes to justify proposed WCMSA amounts.

A link to the announcement may be found here.

What are the implications of this announcement from CMS?

No immediate change to CMS MSA review policies

Importantly, this is an announcement of an expected change to the MSA re-review process and the introduction of a UR policy in 2017. CMS provides no timeline beyond future announcements will occur in 2017. Consequently, there is presently no change to CMS MSA review processes or policies.

Substantial change in medical may present opportunities for revised MSA approvals

The announcement implies CMS will be expanding its MSA re-review process to cover MSA approvals where there has been a “substantial change” in the claimant’s medical condition. According to the CMS statement, this policy would only apply to cases “where settlement has not occurred.” In other words, if settlement has occurred (we assume settlement of medical) CMS will not consider a re-review.

Based upon the limited announcement it is also unclear how CMS will define “substantial change.” For example, must an actual reduction in medical care and/or prescription medication use be documented or simply a certain monetary threshold increase or decrease versus the prior MSA amount be demonstrated? This is an important question CMS will have to address as while a claimant’s medical care may not have substantially changed, the cost of the claimant’s prescription medications may have substantially reduced such as when a medication goes generic.

While the definition of “substantial change” will be the subject of a future CMS policy announcement, Tower MSA nonetheless expects this MSA Re-Review expansion to present a significant opportunity for carriers/employers and claimants to settle medical on cases which have languished unsettled for years as a result of prior high CMS MSA approvals. Reductions in a claimant’s medical costs over the years or the successful implementation of a plan to reduce a claimant’s inappropriate prescription medication regimen will yield not only a lower MSA allocation, but CMS approval of this updated MSA. The opportunity for an updated and lower MSA will facilitate claim settlements and closures.

Wait and see approach warranted regarding CMS policy on URs

The extent CMS will recognize state Utilization Review processes remains unclear based upon this announcement. Presently, CMS generally recognizes California UR determinations as a limitation on medical care in the MSA if upheld through the statutory Independent Medical Review (IMR) process as the IMR component is understood by CMS to be a final determination subject to appeal only under very limited circumstances. Other state UR processes have not been recognized as they are not considered by CMS to be final determinations. Accordingly, Tower MSA recommends taking a wait and see approach to how CMS defines its policy on URs in MSAs.

Concluding thoughts

Tower MSA applauds the potential expansion of the CMS MSA Re-Review process to encompass pre-settlement MSA approvals where there has been a substantial change in medical care as this gives carriers/employers and claimants a second-chance to settle long-standing open medical claims. We are also hopeful CMS will expand its policy on recognizing state UR process beyond California’s IMR process. We will closely monitor CMS for an announcement concerning the implementation of this policy change and provide you further analysis and recommendations.

If you have any questions regarding this CMS announcement please contact Dan Anders, Tower MSA Chief Compliance Officer, at (847) 946-2880 or Daniel.anders@towermsa.com

Workcompcentral Highlights Tower MSA CEO Rita Wilson’s “Edge” in MSP Compliance Technology

December 20, 2016

Tower MSA Partners CEO, Rita Wilson, is the subject of a recent Workcompcentral article, Focus on Tech Has Guided MSP Compliance Co. CEOs Career, highlighting how Rita’s career in building better pharmaceutical and worker’s compensation technology systems led her to develop a Medicare Secondary Payer (MSP) technology platform which electronically integrates medical and cost-containment information.

In discussing why the MSP compliance technology platform is a difference maker for Tower MSA, Workcompcentral’s Emily Brill quotes Rita:

Tower MSA has differentiated itself by building out a software system that monitors and shares claim information from beginning to end, integrating medical and cost containment information for “continuity” and to avoid “reinventing the wheel” by scrambling to get information from separate sources.

The article further quotes Rita in explaining how the platform assists Tower MSA in providing MSP compliance services to its clients:

Our technology platform is able to track claim information all the way through, through the conditional payment research process, through the intervention process, through the MSA process. What we did was integrate this information and track it with one software application that allows us to measure the progress each month, and determine when the right time to finalize the MSA.

In understanding the benefits of Rita’s focus on technology in MSP compliance, Ms. Brill spoke to Ann Schnure, the former Vice-President of Risk Management for Macy’s, and also a strong proponent of the use of technology in claims handling, who said of Rita:

Wilson’s focus on technology has always given the CEO an edge.

Learn more about Tower MSA Partners Chief Executive Officer Rita Wilson,  connect with her on LinkedIn and view her blog posts on our MSP Compliance Blog.

To learn more about how Tower MSA Partners’ technology platform can give you an “edge” in Medicare Secondary Payer Compliance please contact Rita Wilson at rita.wilson@towermsapartners.com or 888.331.4941.

CMS Technical Alert Confirms $750 Threshold for Liability, WC and No-Fault TPOC Reporting

December 13, 2016

In a 12/12/2016 Technical Alert, the Centers for Medicare and Medicaid Services (CMS) confirmed their prior policy announcements concerning the implementation of a $750 threshold for the reporting of Total Payment Obligation to the Claimant (TPOC) through the Section 111 Mandatory Insurer Reporting process. The $750 threshold for TPOC reporting in WC and No-Fault claims became effective 10/1/2016 and will become effective for liability claims effective 1/1/2017.

The mandatory reporting threshold requirements are now as follows:

Liability Insurance:
The mandatory reporting threshold for liability insurance (including self-insurance) Total Payment Obligation to the Claimant (TPOC) Amounts dated January 1, 2017 or after is changing from $1000 to $750. If the most recent TPOC Date is on or after January 1, 2017, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported.

Note, the liability threshold only applies to physical trauma-based liability insurance TPOC amounts. It is not applicable to TPOC amounts for alleged ingestion, implantation or exposure.

No-Fault Insurance:
The mandatory reporting threshold for no-fault insurance TPOC Amounts dated October 1, 2016 or after changed from $0 to $750. If the most recent TPOC Date is on or after October 1, 2016, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported.

Workers’ Compensation:
The mandatory reporting threshold for workers’ compensation TPOC Amounts dated October 1, 2016 or after changed from $300 to $750. If the most recent TPOC Date is on or after October 1, 2016, and the cumulative TPOC Amount is greater than $750, the TPOC(s) must be reported

CMS also announced that as of 1/1/2017 reporting of cumulative TPOC Amounts at or below the above defined reporting thresholds will be accepted, but are not required. In other words, submitting a TPOC amount below the mandatory reporting thresholds will no longer generate an error code by CMS.

The entire content of the official Alert from CMS can be found here.

If you have any questions regarding this Alert please contact Tower MSA Partners’ Chief Compliance Officer, Dan Anders, at Daniel.anders@towermsa.com or (847) 946-2880.

Tower MSA Partnership with American Airlines and PRIUM Yields Legacy Claim Settlements

December 8, 2016

In a widely acclaimed presentation at the recent 2016 National Workers Compensation and Disability Conference, Jennifer Saddy, Workers’ Compensation Director for American Airlines and Mark Pew, Senior Vice President of PRIUM, detailed the successful cooperation among American, PRIUM and Tower MSA to reduce pharmacy costs, litigation referrals and Medicare Set Aside costs ultimately leading to significant claim settlements.  Tower MSA is grateful to Jennifer and Mark for highlighting how Tower MSA’s Identification, Intervention and Involvement services were a key contribution to the success of this legacy claim reduction program.
 
For more information on American’s program please read the Risk & Insurance article Make a Decision and Move the Needle: American Airlines needed to take aggressive action to resolve 6,000 lingering workers’ compensation claims.

For more information on Tower MSA’s legacy claim reduction services please contact us at 888.331.4941 or info@towermsa.com.

Selecting the Right MSP Compliance Service Provider

June 30, 2016

Please take a moment to read Michael Stack’s article outlining qualities needed in selecting the right MSP compliance service provider.. Medicare Secondary Payer compliance is complicated and penalties can be high. There are a lot of components – Section 111 reporting, Conditional Payments, medical and pharmaceutical interventions, legal interventions, and Medicare Set Aside (MSA) preparation.

Typically these various activities are handled in silos, and time lags and errors can occur during the transfer to the next step. It’s easy to miss a data field or deadline.

In his article, Stack notes that:

“Effective MSP compliance includes a service provider that goes beyond the basics. These providers will offer services that allow members of the claim management team to focus on their job and provide information and resources to comply with Medicare regulations in workers’ compensation claims.”

Tower recognizes that Section 111, Conditional Payments, pre-MSA Triage, all interventions, and MSA preparation through CMS acceptance should occur in a continuous, unbroken process. That’s why we developed an all-inclusive MSP Automation Suite around compliance best practices. Our MSP Automation Suite drives the entire compliance process, automatically updates clients of each activity on the file, escalates medical and pharmacy issues, prompts for interventions and much more.

Claims close faster, quality and accuracy are assured and our clients enjoy smooth settlements. To learn more, contact us at info@TowerMSA.com or 888-331-4941.

 

Related posts on compliance:

Tower’s Medicare Secondary Payer (MSP) Compliance Countdown

The Year in MSP Compliance (2019)

How Do You Know Your MSP Compliance Data is Secure?