News Archives - Page 17 of 19

Enhanced Portal Functionality for Final Conditional Payment Process

November 10, 2015

In its ‘What’s New’ section, CMS announced on November 9, 2015 that as part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final Conditional Payment (CP) process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.

When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP. Once calculated, this amount will remain the Final Conditional Payment Amount as long as:

The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.

How the NGHP recovery process works today

To understand the value of this announcement to simplify the final demand process, we need to revisit the recent changes in NGHP recovery and the new role of the Commercial Repayment Center (CRC).

Effective October 5, 2015, the CRC assumed responsibility for pursuing recovery directly from the applicable plan. Any recoveries initiated by the Benefits Coordination & Recovery Center (BCRC) prior to the October 2015 transition will continue to be the responsibility of the BCRC. The typical recovery case, where Medicare is pursuing recovery directly from the applicable plan, now involves the following steps:

1. Medicare is notified that the applicable plan has primary responsibility

Medicare may learn of other insurance through a Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 report or beneficiary self-report. If Medicare is notified that the applicable plan is primary to Medicare, Medicare records are updated with this information.

2. CRC searches Medicare records for claims paid by Medicare

The CRC begins identifying claims that Medicare has paid that are related to the case, based upon details about the type of incident, illness, or injury alleged. The claims search will include claims from the date of incident to the current date. If a termination date for Ongoing Responsibility for Medicals (ORM) has already been reported, the CRC will collect claims through and including the termination date.

3. CRC issues Conditional Payment Notice (CPN) to the applicable plan

The CPN provides conditional payment information. It advises the applicable plan that certain actions must be taken within 30 days of the date on the CPN or the CRC will automatically issue a demand letter. This notice includes a claims listing of all items and services that Medicare has paid that are related to the case. It also explains how to dispute any items and services that are not related to the case. A courtesy copy of the CPN is sent to the beneficiary and beneficiary’s attorney or other representative. The applicable plan’s recovery agent will also receive a copy of the CPN if the recovery agent’s information was submitted on the applicable plan’s MMSEA Section 111 report or the applicable plan has otherwise appointed a recovery agent by submitting a written authorization to the CRC.

Note: If a beneficiary or his or her attorney or other representative reports a no-fault insurance or workers’ compensation situation before the applicable plan submits a Section 111 report, the applicable plan will receive a Conditional Payment Letter (CPL). The CPL provides the same information as a CPN, but there is no specified response timeframe. When this occurs, the applicable plan is encouraged to respond to the CPL to notify the CRC if it does not have ORM and will not be reporting ORM through Section 111 reporting or if the applicable plan would like to dispute relatedness.

4. Applicable plan submits a dispute

The applicable plan has 30 days to challenge the claims included in the CPN. The applicable plan may contact the CRC or use the Medicare Secondary Payer Recovery Portal (MSPRP) to respond to the CPN.

5. CRC issues recovery demand letter advising plan of monies owed to Medicare

The demand letter advises the applicable plan of the amount of money owed to the Medicare program and requests reimbursement within 60 days of the date of the letter. A courtesy copy of the demand letter is sent to the applicable plan’s recovery agent, the beneficiary and the beneficiary’s attorney or other representative. The demand letter includes the following:

The beneficiary’s name and Medicare Health Insurance Claim Number (HICN);
Date of accident/incident;
A claims listing of all related claims paid by Medicare for which Medicare is seeking reimbursement from the applicable plan; and
The total demand amount (amount of money owed) and information on administrative appeal rights.

If the CRC agrees with disputes submitted timely, unrelated claims will be removed from the case before the demand letter is issued. Please note that the demand letter may include related claims that Medicare paid after the CPN was issued. Relatedness disputes on all claims included in the demand letter may be addressed by submitting an appeal.

6. Applicable plan submits an appeal

An applicable plan has 120 days from the date the applicable plan receives the demand letter to file an appeal. Receipt is presumed to be within 5 calendar days absent evidence to the contrary.

7. Applicable plan submits payment

If the CRC receives payment in full, it will issue a letter stating that the specified debt has been resolved. The letter will also note that new cases may be created if the applicable plan maintains ORM or the CRC receives information on additional items or services paid by Medicare during the period of ORM.

Facilitating timely and more accurate final demands

Because the CRC retains the right to create new cases as long as the applicable plan maintains ORM, timely notification of a final settlement is extremely critical to terminate the recovery efforts of the CRC. We applaud the addition of CP process functionality to the MSPRP as a segue to real time information and data exchange, and a more predictable outcome.

With more timely submissions and a published timeline for the final demand, this new extension of the SMART Act will facilitate better accuracy, a better path to closure and fewer last minute surprises…. all good things for those who represent the settlement interests workers’ compensation and liability carriers.

Tower MSA Partners’ Kristine Wilson Will Participate on the MSP/MSA Compliance Panel at California Workers’ Compensation & Risk Conference

October 1, 2015

Wilson will discuss CMS changes to conditional payments and other compliance issues

DELRAY BEACH, Fla.–(BUSINESS WIRE)–Kristine Wilson, COO and senior legal counsel for Tower MSA Partners, will speak at the California Workers’ Compensation & Risk Conference. Tower MSA Partners provides Medicare Set-Aside compliance services nationally and specializes in reducing medical and pharmacy costs on claims prior to settlement.

Wilson will participate on the “MSP/MSA Compliance Open Mic” panel. Topics include whether or not to submit an MSA to the Centers for Medicare and Medicaid Services, the re-review process, and SMART Act changes that affect claims occurring after October 5, 2015. Moderated by Safety National’s Mark Walls, the panel also features Jake Reason with EK Health, Russell Whittle of Examworks, and Tony Comas with Burns White.

“The SMART Act allows for an appeal process for conditional payment disputes,” said Wilson.

The conditional payment process is also changing. “The big news is that Medicare will seek reimbursement for conditional payments prior to settlement,” Wilson said.

Medicare’s new contractor, Commercial Repayment Center, will issue conditional payment notifications when an entity indicates its ongoing responsibility for medical. “Payers only have 30 days to dispute notifications before a conditional payment demand goes out,” Wilson said. “To mitigate their exposure, payers should ensure their Mandatory Insurer Reporting data is complete and immediately respond to conditional payment notices.”

The California Workers Compensation and Risk Conference will be held September 30 through October 2 at the St. Regis Hotel in Dana Point, Calif., and more information is available at http://www.cwcriskconference.org.

About Tower MSA Partners

Headquartered in Delray Beach, Fla., Tower MSA Partners’ services include pre-MSA Triage, MSAs, physician peer reviews, CMS submissions, MSA administration, medical cost projections, life care plans, conditional payments, and Section 111 reporting. With more than 50 years combined experience in pharmacy, legal oversight and medical care, Tower proactively stages claims, working collaboratively with clients to identify issues and intervene to modify outcomes. Tower remains involved in the claims, through final resolution, MSA and/or other settlement. This model enables Tower’s clients to provide better care to injured workers, reduce claim and MSA costs, and obtain CMS acceptance of the MSA. For more information, visit www.TowerMSA.com and www.MSPComplianceBlog.com.

Contacts
For Tower MSA Partners
Helen Knight, (813)690-4787
helen@kingknight.com

You may view the original article here.

Martin Petro Joins Tower MSA Partners

June 23, 2015

Petro delivers more than 20 years’ experience in business administration, utilization review, case management, and pharmaceutical management to the fast-growing Medicare secondary compliance and MSA company.

“Martin’s clinical proficiency and business acumen, along with his MSA background, position him to run with our business model,” said Tower CEO Rita Wilson.

Most recently Petro was general manager for BioScrip Infusion Partners in Melbourne, Florida. Responsibilities encompassed management and profit and loss results for all departments, including operations, pharmacy, nursing, and customer relations.

“Tower is dedicated to reducing unnecessary medical and pharmaceutical overutilization on claims, getting ahead of potential obstacles to settlements and resolving all issues prior to preparing MSAs,” Wilson added. “Martin understands these issues and shares Tower’s proactive philosophy.”

A registered nurse, with a Bachelor of Science degree in nursing from the University of Pittsburgh and a Master of Business Administration degree from Nova Southeastern University, Petro started his career in utilization management and nurse case management. Previous employers include Broadspire, Gould and Lamb, and Express Scripts.

Join Us In Vegas… Ask How Tower Triage Can Save Millions

October 29, 2012

Wednesday, Nov 7-9 Las Vegas Convention Center.

For 20 years, the National Workers’ Compensation and Disability Conference® & Expo has been the industry’s leading training event. And this year’s event is taking it to the next level – making it the best ever!

Key NWCD presentation tracks include the following:

A new full set of sessions will explore and deliver tangible, actionable solutions to the opioid crisis in workers compensation.
New ‘Regional Differences Sessions’ will each tackle the most challenging issues in a particular area of the country and provide you with practical strategies to overcome them.
New interactive ‘Think Tanks’ give attendees an opportunity to exchange innovative ideas with industry peers and leaders.
Enhanced legal track for attorneys and non-attorneys via partnership with LexisNexis.

Click here for more info on NWCD.

And for those who seek the latest in optimized settlement and Pre-MSA intervention strategies, stop by Booth #936 to learn more about the challenges of the current CMS review model and what Tower MSA Partners is doing to save clients millions.

Tower Triage enables employers and carriers to:

Mitigate CMS exposure
Optimize patient care
Expedite settlement

For more information , or to request a meeting with one of our executive team members, email us at info@towermsa.com.

Is an Illegal Immigrant Entitled to Workers’ Compensation Benefits?

Is an illegal immigrant working in this country entitled to benefits under the Workers’ Compensation statutes? This question was answered in the affirmative in the Delaware Superior Court case, Del. Valley Field Servs. V. Ramirez, No. 12A-01-007-JOH (Sept. 13, 2012).

Saul Ramirez began working as an independent contractor in April 2010, and then working as a regular employee an added to payroll in January 2011. Mr. Ramirez’s boss requested a Social Security number in order to include him on payroll. Responding to that request, Mr. Ramirez furnished a fake Social Security card.

Shortly after being converted to a full-time employee, Mr. Ramirez fell down some stairs and injured his back. The accident was witnessed by the company’s president and reported the accident. It was determined by the treating physician that Mr. Ramirez was totally disabled.

In February, the company was informed by the payroll service that Mr. Ramirez’s Social Security number was false and Mr. Ramirez was subsequently deported in March.

Employer argued that employee (Mr. Ramirez) was not entitled to Workers’ Compensation benefits because:

Employee’s “fraudulent inducement” in falsifying documents to gain employment;
Mr. Ramirez’s deportation suspended benefits;
If Mr. Ramirez could not be lawfully hired pursuant to federal immigration laws, the State’s workers’ compensation laws were preempted.

The Board rejected those arguments stating that despite Mr. Ramirez’s illegal status and falsifying documents, he still qualified as an “employee” under the Workers’ Compensation Act (“Act”). The information Mr. Ramirez falsified was not the type of information that would make him forfeit his rights as the falsification did not pertain to his health, work history, or prior injuries.

Next, the Board stated that federal law did not prohibit the award of benefits to an illegal alien. Also, the inability of Mr. Ramirez to return to the United States for treatment did not forfeit his right to benefits as he was not “refusing” treatment as defined in the Act.

The main issue in this case was not one of immigration law, it was labor law. Mr. Ramirez was hired by the company to perform work. He was injured on the job and required medical treatment. There was no dispute about the actual injury. The employer received the bargained-for benefit of the employment relationship. This case has been appealed to the Delaware Supreme Court.

Another state takes up the fight against Prescription Drug Abuse….

October 24, 2012

Fight Against Prescription drugs

Another state takes up the fight against Prescription Drug Abuse….
“Kentucky House Bill 1, sponsored by House Speaker Greg Stumbo, passed in a special legislative session this spring and went into effect July 20. The bill included multiple elements to prevent the abuse and diversion of prescription drugs and to enhance law enforcement’s tools to investigate illegal prescribing practices. Since its implementation, 10 pain management clinics have closed, prescriptions for some of the most-abused controlled substances are dropping, and a record number of investigations are under way into suspicious prescribing practices,

For workers’ compensation carriers and employers, this is a tremendous victory in the fight to prevent prescription drug abuse by injured workers. We believe more states should follow Kentucky’s lead.

Things My Mother Taught Me

She taught me a LOT!

My mother taught me TO APPRECIATE A JOB WELL DONE.
³If you¹re going to kill each other, do it outside. I just finished cleaning.²

My mother taught me RELIGION.
³You better pray that will come out of the carpet.²

My mother taught me about TIME TRAVEL.
³If you don¹t straighten up, I¹m going to knock you into the middle of next week!²

My mother taught me LOGIC.
³Because I said so, that¹s why.²

My mother taught me MORE LOGIC.³If you fall out of that swing and break your neck, you¹re not going to the store with me.²

My mother taught me FORESIGHT.
³Make sure you wear clean underwear in case you¹re in an accident.²

My mother taught me IRONY.
³Keep crying, and I¹ll give you something to cry about!²

My mother taught me about the science of OSMOSIS.

³Shut your mouth and eat your supper.²

My mother taught me about CONTORTIONISTS.
³Will you look at that dirt on the back of your neck!²

My mother taught me about STAMINA.
³You¹ll sit there until all that spinach is gone.²

My mother taught me about WEATHER.
³This room of yours looks as if a tornado went through it.²

My mother taught me about HYPOCRISY.³If I told you once, I¹ve told you a million times, don¹t exaggerate!²

My mother taught me the CIRCLE OF LIFE.
³I brought you into this world, and I can take you out..²

My mother taught me about BEHAVIOR MODIFICATION.
³Stop acting like your father!²

My mother taught me about ENVY.
³There are millions of less fortunate children in this world who don¹t have wonderful parents like you do.²

My mother taught me about ANTICIPATION.

³Just wait until we get home.²

My mother taught me about RECEIVING.
³You are going to get it when you get home!²

My mother taught me MEDICAL SCIENCE.
³If you don¹t stop crossing your eyes, they are going to get stuck that way.²

My mother taught me ESP.
³Put your sweater on; don¹t you think I know when you are cold?²

My mother taught me HUMOR.³When that lawn mower cuts off your toes, don¹t come running to me.²

My mother taught me HOW TO BECOME AN ADULT.
³If you don¹t eat your vegetables, you¹ll never grow up.²

My mother taught me GENETICS.
³You¹re just like your father.²

My mother taught me about my ROOTS.
³Shut that door behind you. Do you think you were born in a barn?²

My mother taught me WISDOM.
³When you get to be my age, you¹ll understand.²

My mother taught me about JUSTICE.³One day you¹ll have kids, and I hope they turn out just like you!²

Court Urges Change in Florida Workers¹ Compensation Law

Court Urges Change in Florida Workers¹ Compensation Law. An appellate court is urging the Florida Legislature to reconsider a state law that makes injured employees pay employers¹ legal costs if they lose good faith workers¹ compensation appeals.
A three-judge panel of the 1st District Court of Appeal in Tallahassee made that recommendation in upholding such an order. It requires Gina Frederick to pay the Monroe County School District $11,834.
There¹s no dispute Frederick was hurt on the job, but two doctors disagreed on whether she had a permanent total injury. A medical adviser appointed by a compensation claims judge, though, offered the opinion she¹s not totally and permanently injured.
Frederick then withdrew her claim but still was ordered to pay the district¹s costs. The court noted the law on the other hand limits fees for workers¹ lawyers.
Copyright 2012 Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Source

Annual WCCP Holiday Conference!

October 18, 2012

Tower MSA Partners will be a sponsor of the Annual WCCP Holiday Conference! The event will be held at the Intercontinental Hotel in Tampa, FL on November 30, 2012. Registration begins at 7:30 a.m., with the conference starting at 8:30 a.m. After a full day of education, be sure to join us for our Sponsored Holiday Reception. This year we will be partnering with the Rough Riders for our 1st Annual Teddy Bear Drive. While this is the end of our educational season, it is one of the Rough Riders first events of the year, so let’s make it memorable! Challenge your peers to see who can donate the greatest number of bears while increasing your chance to win the WCCP Holiday Door Prize. Teddy bears must be between 12″ and 16″.

Upcoming CEU at the new Buca di Beppo.

Tower MSA Partners will be sponsoring an After Hours CEU at the new Buca di Beppo in the Governor’s Square Mall in Tallahassee this Thursday, October 18, 2012, starting at 5:30 P.M. We will be presenting “Important Deadlines” for a 1hr Law credit and “Tips For Employers On How To Save On WC Cost”. Heavy hor d’oeuvres and drinks provided to make sure no one goes hungry.