News Archives

Pre-MSA Triage Works!

January 21, 2016

Inappropriate and/or unnecessary prescription drugs, along with recommended medical procedures that are recommended, but never performed, are all too common in workers’ compensation claims. Yet they are often overlooked when moving a claim to settlement. But a new tool is helping payers identify and address obstacles, saving millions of dollars in MSA and settlement costs. Several recent cases bear out the program’s success.

Tower MSA Partners developed this unique service to ensure MSAs include only accurate and appropriate medical and pharmaceutical treatment. The Pre-MSA Triage allows payers to stage claims for optimal outcomes by providing a snapshot of MSA exposure before the MSA. By following our recommended interventions, clients are achieving CMS approval of reduced MSAs, with reductions of more than 50% in many cases.

How it works

Tower analyzes 6 months of medical records to identify care and cost issues, including the projected MSA cost of a claim based on the current medical and pharmacy treatment regimen. The review also provides a snapshot view of the MSA exposure in a non-discoverable (not an MSA) format, and offers an overview of inappropriate, unnecessary treatment and cost drivers that may impact MSA and settlement. For example, the review may uncover denied injuries and/or body parts, recommended surgical procedures that were never pursued, spinal cord stimulators that were recommended but never evaluated, gaps in treatment dates, unrelated medications, and off-label drug usage.

We then recommend various interventions, such as physician peer review, clinical oversight and conditional payment searches/negotiations to effect improved outcomes and savings in the overall claim costs, frequently as much as 50 percent!

Example Case Study

Tower’s Pre-MSA Triage projected the MSA cost for a 46-year-old male at $1,300,000. More than $1,000,000 of the total projection was due to extended prescribing of both long and short acting opioids. Tower recommended a Physician Peer Review followed by direct dialogue with the treating physician. Agreement to wean was obtained in writing and Tower initiated its clinical nurse oversight service to track progress.

Through Tower’s MSP Automation Suite, developed and maintained internally, we were able to drive the weaning process with the physician through tracked monthly calls, and to guide the adjuster as to when discontinued medications should be blocked by the client’s PBM.

Upon finalization of the weaning process, Tower worked with defense to obtain the necessary written language from the treating physician to confirm discontinuation and remove past medications. The final MSA was submitted and approved by CMS for $210,641 – a savings of more than $1,000,000 from the original estimate!

Conclusion

The example provided here is one of many success stories we are seeing, and through our MSP Automation Suite, we’ve been able to manage the process from triage through final CMS submission and approval in a secure, digital environment. Whether handled internally by our team of nurses or through a formal intervention and peer dialogue by one of our physicians, our system drives every step in the process.

Many companies can identify problems, and some even make recommendations. At Tower, we believe the key to successful MSA outcomes is a proactive approach to identify, intervene and remain involved through closure.

CMS Announces Portal Functionality for Final Conditional Payment Process

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.

Closed Formularies Hold Promise for Workers’ Compensation Pharmacy Management

With the signing of A.B. 1124 by Governor Jerry Brown October, California has now joined a handful of states that have adopted closed pharmaceutical formularies in their workers’ compensation systems. While many details have yet to be worked out, the decision comes as good news for injured workers and payers alike.

Closed formularies essentially use evidence-based medicine to identity the prescription drugs that should be allowed for certain injuries. All other medications must go through a preauthorization process. The idea is to ensure the injured worker gets the right medication at the right time for the right reasons – AND to reduce unnecessary pharmacy costs.

Implemented appropriately, a formulary can result in better outcomes and lower costs. In fact, a study last year suggested California’s workers’ compensation system could save between $124 million and $420 million annually by adopting a formulary similar to that in effect elsewhere.

In addition to the states that have already implemented closed formularies or are in the process of doing so, several others are considering the idea. The result could be better efficiencies and significant savings for Tower MSA Partners’ clients in managing workers’ compensation claims even before the Medicare Set Aside review and triage process.

The specifics

Under A.B. 1124, the administrative director of California’s Division of Workers’ Compensation must create a formulary by July 1, 2017 for medications prescribed to injured workers. Between now and then, California regulators must determine a program that best addresses the needs of California’s injured workers.

Four states – Ohio, Oklahoma, Texas and Washington have implemented closed drug formularies. Arizona, Arkansas, California, Louisiana, Maine, Michigan, Montana, Nebraska, North Carolina and Tennessee are among the other states considering the formularies or in the midst of developing them.

There are several different types of formularies in effect. Washington, which adopted the first such formulary in 2004, has a more restrictive program than those in some other states. Texas, on the other hand includes more therapeutic groups and more choices within each group.

Regardless of the type of formulary, the states have touted successes. Texas, Washington and Ohio have all reported lower costs.

Texas, which implemented its closed formulary for new injuries in September 2011 and for all injuries in September 2013, also reported the number of injured employees receiving ‘N’ drugs – those requiring preauthorization – fell 65% and costs dropped 83% for new claims for injuries suffered on or after Sept. 1, 2011. Also important, the formulary has led to a significant reduction in the number of injured workers taking opioids on a long-term basis.

The Ohio Bureau of Workers’ Compensation likewise reported significant utilization and cost declines, including a 74% drop in skeletal muscle relaxants, a 25% decline in narcotics and a total drug cost drop of 16%, for a total of $20.7 million, in fiscal year 2014 compared with fiscal year 2011.

Many decisions must be made before California’s formulary takes effect and a variety of issues must be addressed. For example, the pre-approval process for drugs not allowed, decisions about the strategy for long-time opioid users, and considerations of compound medications must be determined.

Fortunately, a team of workers’ compensation stakeholders involved in helping to craft the legislation ensured some important provisions were included. The law requires the California Division of Workers’ Compensation to update the formulary at least quarterly, establish an independent pharmacy and therapeutics committee, accept public comment and publish two interim status reports

Supporters are confident when all is said and done, California’s formulary will provide effective treatment for injured workers, reduce delays and medical disputes, and reduce costs.

How closed formularies impact claims and MSAs

Closed formularies can serve as a gatekeeper in preventing troublesome medications being prescribed to injured workers. Medical providers in states with closed formularies tend to change their behavior and prescribe more clinically appropriate medications and treatments rather than unnecessary opioids and other drugs that require preauthorization.

While providers need approval to be reimbursed for medications not automatically allowed, supporters say closed formularies do not seek to prevent injured workers from having access to medications that are truly beneficial to them.

Workers’ compensation payers can also look for less adversarial relationships with providers, since there will be fewer questionable medications prescribed for the injured worker. Drugs that are not appropriate for first line therapy are generally those that are not allowed without prior authorization, under the closed formularies.

Many steps must be taken before California’s closed drug formulary will take effect and the devil is surely in the details. However, the fact that the nation’s largest workers’ compensation market is going in this direction is good news indeed!

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

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.

Enhanced Portal Functionality for Final Conditional Payment Process

November 10, 2015

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).

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

2. CRC searches Medicare records for claims paid by Medicare

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

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 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

Facilitating timely and more accurate final demands

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.

“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.

About Tower MSA Partners

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.