News Archives - Page 18 of 19

Good News From PA Court – ACTIQ Not Reasonable in Workers’ Comp Back Injury

October 10, 2012

The Pennsylvania Commonwealth Court, in a decision published late last month, seized upon Fentanyl (ACTIQ), a highly addictive opioid, 100 times more powerful than morphine, when it ruled specifically that Fentanyl lozenges were not appropriate as treatment for a workers’ compensation low back injury. According to defense counsel, Ronald A. Varga, the decision of the Court “could be significant” as it provides carriers with “a mechanism to cut of this medication and switch to something else”.

The original dispute occurred after Utilization Review findings concluded that the Fentanyl lozenge was not appropriate and necessary treatment for a low back injury because of its highly addictive nature and because its only approved use is listed as end stage cancer pain. The original decision, made by the Workers’ Compensation Board, found that the risk of addictive and potential danger to the patient is a valid and reasonable basis for the determination of the appropriateness and necessity of a treatment regimen. Upon appeal, however, divided Workers’ Compensation Appeals Board (WCAB) overturned the decision, noting that the availability of alternative treatment options “does not, in and of itself, render claimant’s current pain management unreasonable or unnecessary”.

The Commonwealth Court, in its reinstatement of the original ruling, noted the following:

1. The utilization review process is the sole method for determining if a disputed treatment is reasonable and necessary.
2. In making its determination of reasonableness and necessity, it is entirely appropriate for UR reviewer to consider the risk to the patient.
3. The reviewer in this case was within his rights to “consider whether it is reasonable and necessary for a provider to expose his patient to the level of risk presented by a medication”.
4. The weight and credibility of a utilization reviewer’s findings is for the workers’ compensation judge to decide.

As a resource for other employers, it is likely that we’ll see this decision cited as justification to contest the use of this very dangerous opioid. If an employer or insurance company can obtain objective medical opinion that the treatment the patient is receiving is highly addictive and there are alternatives to the use of narcotics, this case will certainly support an effort to challenge the prescription.

For more information on the decision and its implications, see https://ww3.workcompcentral.com/news/story/id/b8df217867f36a5641fbd85e9bcb5dd7s (subscription required).

Christy Weir, RN, Joins Tower MSA Partners as Regional Vice President

July 18, 2012

Tower MSA Partners is pleased to introduce Christy Weir as the newest addition to its national sales team for Medicare Secondary Payer services.

A native of Atlanta, Georgia, Christy will be responsible for both southeast regional and national accounts for Medicare Set Aside and Medicare Secondary Payer compliance services. Christy has more than 15 years experience in providing cost containment services in the workers’ compensation and disability market.

Christy served the industry in various capacities, beginning her career as a registered nurse and case manager, and transitioning into sales more than 10 years ago. Prior to joining Tower MSA Partners, Christy served the workers’ compensation market in local and regional roles involving both management and sales specific to Medicare Set Aside, Pharmacy Benefit, and Case Management Services.

Christy received her nursing degree from Dekalb College School of Nursing and maintains her license as a registered nurse in the state of Georgia.

Tower is pleased to have someone with Christy’s solid reputation for professionalism, sales and service as part of our organization, and we look forward to participating in her many successes. Christy can be reached via email at christy.weir@towermsa.com, or via phone at 678-787-9412.

Coming Soon – The Medicare Secondary Payer Recovery Portal

May 17, 2012

A new online Self-Service Tool to help manage your Medicare recovery case.

The Centers for Medicare & Medicaid Services (CMS) is in the process of implementing a new web-based tool designed to assist in and accelerate the resolution of Liability Insurance, No-Fault Insurance, and Workers’ Compensation Medicare recovery cases. The new tool is called, The Medicare Secondary Payer Recovery Portal (MSPRP).

The MSPRP will give users (attorneys, insurers, beneficiaries, and TPAs) the ability to access and update certain case specific information online. Activities that currently require written communication or telephone calls to the Medicare Secondary Payer Recovery Contractor will soon be able to be done through the portal.
The MSPRP will allow users the ability to electronically perform the following activities:
•Submit Proof of Representation or Consent to Release documentation – Instead of mailing in an authorization, users will be able to upload authorizations through the portal.

•Request conditional payment information – Requesting an updated conditional payment amount or a copy of a current conditional payment letter will be as simple as clicking a few buttons.

•Dispute claims included in a conditional payment letter – Users will be able to view the claims listed on the conditional payment letter and dispute unrelated claims online.

•Submit case settlement information – Users will be able to input settlement information online and upload a copy of the settlement documentation through the portal.

The MSPRP is scheduled to go live in July 2012. Additional details regarding the MSPRP will be shared on this website in the coming months.

Tower MSA Partners will be part of the MSPRP rollout. More details will follow as to how to utilize this new electronic service.

New Option to Self-Calculate Your Conditional Payment Amount

January 30, 2012

Just released from MSPRC (http://www.msprc.info/).

On February 21, 2012, the Centers for Medicare & Medicaid Services (CMS) will implement an option that allows certain Medicare beneficiaries to self-calculate Medicare’s final conditional payment amount prior to settlement. A full explanation, including instructions on how and when to elect this option can be found by clicking on the following link:

http://msprc.info/forms/SelfCalculatedFinalCP.pdf

The information provided includes eligibility criteria for this process, instructions on how to self-calculate the final conditional payment amount, CMS’ review process, tips, and an illustrative example for completing this new process.

CMS will continue to improve and refine this process. Therefore, we welcome your input and comments at a future teleconference.

New From MSPRC, A “Self-Calculated Final Conditional Payment Amount” Option

December 19, 2011

The Centers for Medicare & Medicaid Services (CMS) will be implementing an option that will allow certain Medicare beneficiaries to obtain Medicare’s final conditional payment amount prior to settlement. This option will be available in February 2012, for certain settlements involving physical trauma based injuries where treatment has been completed.

Under this option, the beneficiary or his representative will calculate the amount of Medicare’s conditional payment amount using information received from the Medicare Secondary Payer Recovery Contractor (MSPRC), the MyMedicare website, or other claims information available to the beneficiary. The MSPRC will review this amount and, if finding the amount accurate, will respond with Medicare’s final conditional payment amount within 60 days. To secure the final conditional payment amount, the beneficiary must settle within 60 days after the date of Medicare’s response.

In order to use this option, ALL of the following criteria must be met:

The liability insurance (including self-insurance) settlement will be for a physical trauma based injury (the settlement does not relate to ingestion, exposure, or medical implant);
The total liability settlement, judgment, award, or other payment will be $25,000 or less;
The Date of Incident occurred at least six months before the beneficiary or his representative submits his proposed conditional payment amount to Medicare;
The beneficiary demonstrates that treatment has been completed and no further treatment is expected either through a written physician attestation or by certifying in writing that no medical treatment related to the case has occurred for at least 90 days prior to submitting the proposed conditional payment amount to Medicare.

Explicit instructions on how to use this process will be posted on the Medicare Secondary Payer Recovery Contractor’s website at www.msprc.info by January 15, 2012. CMS will leverage existing processes to the greatest extent possible. This is an initial step to provide beneficiaries and their representatives with Medicare’s conditional payment amount prior to settlement. CMS plans to expand this option as it gains experience with this process.

New Fixed Percentage Option For Medicare’s Recovery Claim
Effective November 7, 2011, the Centers for Medicare & Medicaid Services has implemented a new and simple fixed percentage option that is available to certain beneficiaries. This option is available to beneficiaries who receive certain types of liability insurance (including self-insurance) settlements of $5000 or less.

A full explanation, including instructions on how and when to elect this option, is available in the Fixed Percentage Option section of both the Attorney and Beneficiary Toolkits.
Beneficiary Alert: $300 Threshold on Liability Settlements
Medicare has implemented a $300 threshold for certain Liability Insurance cases. If all of Medicare’s criteria are met, the MSPRC will not recover against the beneficiary’s settlement, judgment, award or other payment.

We have posted a detailed explanation in the Attorney and Insurer Toolkits.

Alert: Liability Insurance (Including Self-Insurance) and December 5, 1980 (12/5/1980):
Additional policy details have been provided by the Centers for Medicare & Medicaid Services on liability insurance (including self-insurance) cases involving exposure, ingestion, and implantation. Click the link below to view the update. http://www.msprc.info/forms/Exposure-Ingestion-TDL.pdf.

Workers’ Compensation Medicare Set-aside Portal (WCMSAP)

November 29, 2011

The Center for Medicare & Medicaid Services (CMS) has completed its Pilot Testing of the Workers’ Compensation Medicare Set-aside Portal (WCMSAP). The CMS will be conducting a Town Hall conference call on November 29, 2011 from 1:00 to 3:00 pm (EST), to introduce this initiative to submitters of proposed Workers’ Compensation Medicare Set-Aside Arrangement (WCMSAs) amounts, and to answer questions regarding the WCMSAP. After the Town Hall conference call, CMS will post the links of the WCMSAP application, and the WCMSAP Computer Base Training (CBT) Modules, on the Workers’ Compensation Medicare Set-aside Portal (WCMSAP) section page “Related Links Outside CMS.”

Please Note: The call in information for the WCMSAP Town Hall teleconference is:
Call in time: 1pm to 3pm
Call In Line: 1-(800) 603-1774
*Conference ID: 29840615

*Participants must use the Conference ID number to be allowed into the call.

Top 10 Drugs Prescribed For Workers’ Compensation Claims

November 21, 2011

A recent study by NCCI Holdings, Inc. reports the top 10 most popular drugs prescribed for workers’ compensation claims.

1. OXYCONTIN®
2. LIDODERM®
3. HYDROCODONE-ACETAMINOPHEN
4. LYRICA®
5. CELEBREX®
6. GABAPENTIN
7. SKELAXIN®
8. CYMBALTA®
9. MELOXICAM
10. CYCLOBENZAPRINE HCL

Workers compensation medical costs per claim average more than $6,000 and soar to nearly $25,000 for lost-time claims. The report examined workers compensation prescription drug (Rx) use, a medical expense that makes up 19% of all workers compensation (WC) medical costs.

Other key findings of the report on drugs prescribed for workers’ compensation were:

• The indicated Rx share of total medical is 19%; this is slightly higher than the estimate given in the 2010 update
• OxyContin® climbs from the number 3 WC drug in Service Year 2008 to number 1 in Service Year 2009
• Hydrocodone-Acetaminophen drops from the top WC drug in Service Year 2008 to number 3 in Service Year 2009
• Recent overall cost increases are driven more by utilization increases than by price increases
• Physician dispensing continues to increase in Service Year 2009 in almost every state
• Increased physician dispensing is associated with increased drug costs per claim
• Per-claim Rx costs vary significantly by state

CMS Announces New Fixed Percentage Option For Medicare’s Recovery Claim

October 26, 2011

Certain beneficiaries will be able to resolve Medicare’s recovery claim by paying Medicare 25% of his/her total liability insurance settlement instead of using the traditional recovery process. This means that a beneficiary will know what he/she owes and will be able to immediately pay Medicare.

The Centers for Medicare & Medicaid Services announced that this new and simple fixed percentage option will be available to certain beneficiaries beginning November 7, 2011. This option is available to beneficiaries who receive certain types of liability insurance (including self-insurance) settlements of $5000 or less.

In order to elect this option to resolve Medicare’s recovery claim, the following criteria must be met:

1.The liability insurance (including self-insurance) settlement is for a physical trauma based injury. (This means that it does not relate to ingestion, exposure, or medical implant), and
2.The total liability settlement, judgment, award, or other payment is $5000 or less, and
3.The beneficiary elects the option within the required time frame and Medicare has not issued a demand letter or other request for reimbursement related to the incident, and
4.The beneficiary has not received and does not expect to receive any other settlements, judgments, awards, or other payments related to the incident.

A full explanation, including instructions on how and when to elect this option, will be available on this website on November 7, 2011 in the Fixed Percentage Option section of both the Attorney and Beneficiary Toolkits.

Please Note:When a beneficiary elects this option, he/she must understand that as part of choosing the option he/she will be giving up the right to appeal the fixed payment amount or request a waiver of recovery for the fixed payment amount.

Liability Settlement Solutions

Wyden, Portmam Lead Effort to Make Medicare Secondary Payer Program More Efficient, Save Taxpayer Dollars

October 19, 2011

Wyden, Portman Lead Effort to Make Medicare Secondary Payer Program More Efficient, Save Taxpayer Dollars

Bill Makes Common Sense Reforms to Medicare’s Reimbursement Rules to make it easier for the program to collect from Third Party Payers

FOR IMMEDIATE RELEASE: Monday, October 17, 2011
Jeff Sadosky (Portman) | 202-224-5190
Jennifer Hoelzer (Wyden) | 202-224-3789
Jake Thompson (Nelson) | 202-224-8795
David Ward (Burr) | 202-228-1616

WASHINGTON, D.C. – U.S. Senators Ron Wyden (D-Ore.) and Rob Portman (R-Ohio) are leading a bipartisan effort that includes U.S. Senators Ben Nelson (D- Neb.) and Richard Burr (R-N.C.) to make the Medicare Secondary Payer (MSP) Program more efficient and cost effective to taxpayers. The Strengthening Medicare and Repaying Taxpayers (SMART) Act will speed up the rate by which Medicare and its beneficiaries are reimbursed for costs that should be borne by another party.

“Streamlining third party payment fixes some of the bureaucratic requirements that often stand in the way of Medicare being reimbursed for services that they are not supposed to pay for,” Wyden said. “By making the process more efficient, Medicare will be repaid more quickly and more accurately than before and the repayment process will work the way it was designed to work. An easier repayment process is not just good for Medicare and taxpayers, but also for the beneficiary who should be able to settle their claim more quickly.”

“I am pleased to introduce the SMART Act because it will help strengthen and protect Medicare by ensuring greater reliability and efficiency of Medicare reimbursements,” said Portman. “With Washington’s sky high debt and deficit, we need to do everything we can to ensure that entitlement programs such as Medicare are cost effective and working for the very people they were designed to help.”

“The current Medicare Secondary Payment Program is a bureaucratic mess that often leaves everyone involved in the settlement process – from Medicare beneficiaries to small businesses – unsatisfied,” Sen. Nelson said. “The SMART Act will help the program run more efficiently and reduce unneeded uncertainty for all the parties involved.”

“The lack of transparency and inefficiencies with the current Medicare Secondary Payer process illustrates how Washington’s red-tape and regulatory uncertainty can adversely impact seniors and businesses,” Burr said. “In order to get our economy back on track, we simply cannot afford to continue to waste taxpayer dollars by perpetuating the inefficiencies of the current Medicare Secondary Payer system. We can and must do a better job for the seniors and stakeholders depending upon this program to be as transparent and efficient as possible.”

Under the MSP program, if a Medicare beneficiary is injured by a third party and a settlement is pursued as a result of that injury, the third party is responsible for paying for the individual’s medical expenses. If Medicare, now the “secondary payer,” pays any of the costs associated with the injury, it is entitled to reimbursement.

Several problems exist with the reimbursement process under this scenario. Under current law, Medicare does not have a way to disclose the MSP amount before settlement, creating unnecessary uncertainty that makes it hard to settle cases. Second, there are times when Medicare spends more money pursuing an MSP payment than they actually end up receiving in payment. MSP reporting requirements also require beneficiaries to submit sensitive personal information to the settlement company, causing privacy concerns. Finally, there is no clear statute of limitations on all MSP claims.

The SMART Act will address these issues by creating a process that allows CMS to disclose the MSP amount before settlement so it can be factored into the settlement; requiring Medicare to no longer pursue MSP claims that do not cover their own expenses; directing Medicare to establish an alternative method of identifying individuals so that they don’t have to provide sensitive personal information; and setting a three-year statute of limitations for most claims.

CMS Memoranda

October 17, 2011

October 4, 2011

The Centers for Disease Control (CDC) has recently published its 2007 United States Life Tables. Effective October 31, 2011, the Centers for Medicare & Medicaid Services (CMS) will begin referencing the CDC’s Table 1: Life table for the total population: United States, 2007, for WCMSA life expectancy calculations. This means that for any newly submitted WCMSA proposal received by CMS’ Coordination of Benefits Contractor (COBC), or where any WCMSA case is reopened on or after October 31, 2011, CMS will apply the CDC’s 2007 Table 1 for life expectancy calculations. You may access the CDC’s United States Life Tables in the related links outside of CMS section of this page.