CMS 2024 WCMSA Metrics: Key Trends in Medication and Treatment Costs

December 4, 2024

stethoscope and pill bottle on representing WCMSA trends

CMS 2024 WCMSA Metrics: Key Insights into Costs and Trends

The Centers for Medicare and Medicaid Services (CMS) has released its 2024 data on Workers’ Compensation Medicare Set-Aside (WCMSA) reviews. This year’s metrics highlight two significant trends: declining prescription drug costs and rising medical treatment costs.

For employers, insurers, and other stakeholders, understanding these trends is crucial for effective planning and cost management. Here’s a breakdown of the key findings and how Tower MSA stands out in the industry.

CMS WCMSA Metrics Overview: 2020–2024

CMS’s fiscal year 2024 data provides a five-year perspective on MSA reviews, comparing proposed amounts to CMS-recommended (approved) amounts. Here are the major takeaways:

Consistency in Review Numbers:
CMS completed 14,862 MSA recommendations in 2024, closely aligning with the five-year average of 15,138.
Decrease in Recommendations:
After a 9% rise in recommended amounts between 2022 and 2023, 2024 saw a 6% drop.
Stable Average MSA Amounts:
The average approved MSA decreased slightly to $85,927 in 2024 from $86,453 in 2023. However, this remains above the five-year average of $83,851.
Variance Between Proposed and Approved Amounts:
The variance, which increased to 22% in 2023, remained steady at 21% in 2024.

Key Trends in Costs

Prescription Drug Costs Continue to Decline

CMS data reveals a notable 33% decrease in average prescription drug costs over five years, from $26,574 in 2020 to $17,807 in 2024. This decline reflects:

Reduced opioid use in workers’ compensation cases.
Increased allocation of generic medications over brand-name drugs.

Treatment Costs Are Rising

While prescription costs have fallen, the average treatment costs have increased by 15% since 2020, signaling a shift in the cost structure for MSAs.

How Tower MSA Partners Compares to Industry Averages

Tower MSA Partners has consistently achieved lower costs for its clients, significantly outperforming industry averages in both total MSA and prescription drug components.

Average Approved MSA (2020-2023):
- CMS: $82,332
- Tower: $63,005 (23% lower)
Prescription Drug Component (2020-2023):
- CMS: $22,048
- Tower: $14,286 (35% lower)

Through targeted interventions like our Physician Follow-up service, Tower mitigates costs while ensuring compliance with CMS requirements.

Why CMS Metrics Matter

These annual metrics provide invaluable insights for stakeholders managing workers’ compensation cases. They not only reflect trends in CMS review processes but also offer benchmarks to evaluate cost-saving strategies.

Tower MSA’s cost-effective approach demonstrates that significant savings are possible with a robust review and allocation methodology.

Have Questions? Let’s Connect

If you want to learn more about how CMS metrics impact your workers’ compensation program—or explore cost-saving opportunities—contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or call 888.331.4941.

Empathy in Action: Highlights from WCI

September 6, 2024

Empathy being show by care giver to patient

At the recent Workers’ Compensation Educational Conference in Orlando, FL, empathy took center stage during the WCI-TV segments, sponsored for the ninth consecutive year by Tower MSA Partners. This year’s theme, “Empathy in Workers’ Compensation,” showcased how various industry leaders infuse empathy throughout the claims process, even when they don’t directly interact with injured workers.

Empathy: A vital component

Empathy is a vital component in workers’ compensation, influencing culture, product design, and service delivery across the industry. It ensures that injured workers feel supported and understood, which can lead to improved outcomes, reduced fear, and even a decrease in litigation. By fostering collaboration, care, and consistency, companies across the workers’ compensation landscape are making significant strides in incorporating empathy into their processes.

United Airlines: The Power of Caring

Joan Vincenz, Managing Director of Corporate Safety at United Airlines, spoke about the lasting impact of empathy on injured workers. “People will never forget how they’re treated when they are injured at work. It matters how we treat people when they’re in trouble,” she stated. United Airlines’ philosophy is rooted in safety and care. Beyond preventing injuries, United prioritizes getting immediate, quality care for employees after an injury and helping them navigate the complex workers’ compensation system to return them to health. Vincenz emphasized that the most empathetic thing companies can do is to communicate regularly with injured workers and guide them through the complex workers’ compensation process.

Berkley Industrial Comp: Empathetic Resolution Model

Greg Hamlin, SVP and Chief Claims Officer at Berkley Industrial Comp, highlighted their efforts to embed empathy into the claims process through the Empathetic Resolution Model. This model was developed with input from adjusters on the front lines, who offered suggestions for making the process more human and compassionate. One such suggestion was to rewrite the letters sent to injured workers, making them more empathetic and less formal. Berkley also implemented thoughtful gestures, such as sending cookies to injured workers post-surgery and maintaining regular contact through texts and calls. These small but meaningful actions demonstrate Berkley’s commitment to authentic empathy at every step of the claims process.

Tower MSA Partners: Advocates for Injured Workers

While Tower MSA Partners doesn’t regularly interact with injured workers, it plays a crucial role in supporting claims professionals and attorneys in the settlement process. Kristine Dudley, COO of Tower MSA Partners, explained Tower’s philosophy of the “3 C’s”: Care, Cost, and Compliance. Care, in this context, doesn’t mean providing the most care but rather the most appropriate care for the long-term well-being of injured workers. Tower’s team works closely with treating providers to clarify and confirm treatment plans, ensuring that the right care is included in the MSA. Their aim is to allay fears, answer questions, and make the settlement process as smooth as possible for injured workers.

Ametros: Empathy Through Care and Support

Porter Leslie, CEO of Ametros, emphasized that empathy begins with caring for every individual who interacts with their platform. Ametros’ flagship product, CareGuard, is designed to administer injured workers’ settlement funds, ensuring that they receive ongoing support. At the core of Ametros’ philosophy is “care”, which Leslie describes as the foundation of their empathetic approach. By providing continuous assistance and ensuring that workers feel cared for, Ametros exemplifies how empathy can be embedded in the very fabric of a company’s operations.

The WCI-TV segments at this year’s Workers’ Compensation Conference highlighted how empathy can transform the workers’ compensation experience. From Ametros’ ongoing support to Berkley’s empathetic resolution model and United Airlines’ commitment to caring, companies across the industry are proving that empathy is not just a buzzword but a powerful tool for improving outcomes and reducing litigation. Through thoughtful actions, clear communication, and a focus on the well-being of injured workers, the workers’ compensation industry can continue to evolve with empathy at its core.

Tower-sponsored WCI-TV Segments Focus on Empathy

August 14, 2024

Empathy. We know we need it, but what exactly is it and how do we use it to help injured employees?

The Miriam-Webster dictionary defines empathy as the “action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts and experience of another.” The Society for General Internal Medicine tweaked the definition to apply to healthcare as “the act of correctly acknowledging the emotional state of another without experiencing that state oneself.”

Empathy: A Key to Enhancing Worker Satisfaction and Streamlining Claims in Workers’ Compensation

The workers’ compensation community has embraced the concept of empathy. In articles and at conferences, experts say that injured employees who receive empathy from their providers, employers and insurers report higher levels of satisfaction with their care and are less likely to hire attorneys. It makes sense that an injured worker who feels heard and understood will be more apt to participate in their care, recover faster and return to work. Settlement professionals, like our partner Ametros, have seen empathetic communication break down barriers to the settlement of claims.

So how does one acknowledge the emotional state of another? What does empathy look like in the real world? Is it a skill that can be taught? Can you be too empathetic? Are there ways to incorporate empathy into claims management processes?

Tower will explore these questions during our sponsored WCI-TV interviews. Our guests include Joan Vincenz, Managing Director, Corporate Safety for United Airlines and Greg Hamlin, Senior Vice President and Chief Claims Officer of Berkley Industrial Comp. Other interviews feature Kristi Montoya, Director of Claims Operations for UPS, and Denise Evans, the Director of Claims for Staffmark. Our Chief Compliance Officer Dan Anders and our Chief Operating Officer Kristine Dudley will also share their views.

Tower is the founding sponsor of WCI-TV, which airs during the WCI conference, in hotel rooms and on shuttles as well as on You Tube and WCI’s website. You can see the interviews on Tower’s Linked In home page, too. The 78^th Annual WCI Conference will be held August 18-21 at the Orlando World Center Marriott.

While at WCI, Dan Anders will also moderate a Medicare Secondary Payer Compliance Panel. The “Pre-Settlement Considerations” session runs from 2-3 p.m. on Tuesday, August 20 and features Ametros’ John Kane, Brian Broznowicz with the Centers for Medicare and Medicaid Services, Ringler’s Jarrod Zea, and Kristi Montoya with UPS.

WCI is always busy, but we’d love to catch up with you there! Dan, Kristine Dudley and Hany Abdelsayed will attend the conference. To schedule a meeting before WCI, email daniel.anders@towermsa.com. Otherwise, grab us in the hallways or at the WCI-TV studio.

New Updates to CMS’s WCMSA Reference Guide and Self Administration Tool Kit

August 7, 2024

The Centers for Medicare and Medicaid Services (CMS) recently updated its Workers Compensation Medicare Set-Aside (WCMSA) Reference Guide and WCMSA Self Administration Toolkit. These updates guide MSA administration when the beneficiary is enrolled in a Part C Medicare Advantage Plan or a Part D Prescription Drug Plan.

WCMSA Reference Guide Update

In its Version 4.1 of the WCMSA Reference Guide, CMS added an “Other Health Coverage,” section. Section 4.1.3 says:

… a WCMSA is still recommended when you have coverage through other private health insurance, the Veterans Administration, Medicare Advantage (Part C) or Medicare Prescription Drug Program (Part D)

CMS added the following as an explanation:

Other coverage could be canceled or you could elect not to use such a plan.

This makes sense for private health insurance, which a person may drop after becoming eligible for Medicare. Likewise, a veteran could treat at the VA initially and later seek treatment outside the VA.

However, CMS’s placement of Medicare Part C and D under “Other Health Coverage” is confusing. These are alternative delivery systems for Medicare benefits; a person must be Medicare-covered to use them. And there is no distinction between original Medicare and Parts C and D when it comes to the need for a WCMSA.

The guide makes clear distinctions regarding the coordination of benefits.

CMS notifies Part C and D plan sponsors that a WCMSA has been approved and instructs plan sponsors to conduct Medicare Secondary Payer (MSP) investigations. However, CMS does not relay WCMSA details to plan sponsors. Instead, CMS instructs plan sponsors to seek WCMSA coverage details from the WCMSA administrator as part of the plan sponsor’s investigation. When possible, Part C and D plan sponsors are required to avoid paying for expenses that should be covered by a WCMSA. (Emphasis added.)

It’s unclear why CMS does not provide WCMSA details to C and D plan sponsors as it does with original Medicare. Perhaps it’s a technology issue. From an MSP compliance standpoint, doing so would be beneficial to the plans and the injured worker as well as the taxpayers who pay for these plans.

A Quick Detour to Conditional Payments

After this section, CMS shifts from its WCMSA discussion to this statement on liens:

When a settlement is reached, the settlement details dictate who is responsible for ensuring Medicare (Parts A, B, C, and/or D) is repaid for any conditional payments associated with the WC illness or injury. If the settlement does not identify funds for past debt, CMS considers those debts up to the date of settlement to belong to the WC insurer.

Recovery may be sought from any party receiving inappropriate payment on behalf of the beneficiary.

This highlights the importance of including in the settlement terms which party is responsible for the resolution of Medicare conditional payments, whether from original Medicare or a Part C or D plan.

The Administrator Provides Treatment Details

Then the text returns to WCMSAs with this:

The administrator must provide details concerning treatments and medications used exclusively to treat a related illness or injury to the plan sponsor so the sponsor may avoid making primary payment in the future.

The MSA must either be self-administered by the injured worker or professionally administered by a third party, such as Ametros.

This last sentence in Section 4.1.3 is explained in more detail in the updated Self-Administration Toolkit, Version 1.6:

CMS will tell your Medicare Advantage or prescription drug plan that a WCMSA has been approved. Insurance plans are not given specific information about treatment and medications that should be covered by the WCMSA. You must tell your insurance plan sponsor any details concerning treatments and medications used exclusively to treat a related illness or injury, so they can avoid making primary payment in the future. CMS requires your plan to contact you or the administrator of your WCMSA to find out which expenses are covered by your WCMSA. The plan must avoid paying for expenses that are included in the WCMSA. The plan has a responsibility to recover any payments it made that should have been paid by the WCMSA. If you do not respond to your plan’s investigation efforts, your coverage may be delayed or cancelled.

If you are enrolled in a Medicare Advantage or prescription drug plan, please contact your plan to discuss your WCMSA, if you have not already done so.

Since CMS does not “relay WCMSA details to plan sponsors,” this appears to be how the Part C and D plans learn which diagnoses, treatments, and medications are included in the MSA.

WC Payers and CMS have made tremendous investments into Section 111 reporting and the WCMSA submission and approval processes. Therefore, it is disappointing that the MSA administrator is responsible for communicating with the Part C or D plan.

It remains unclear exactly how the MSA administrator will communicate with the Part C and D plans. Will the plan provide the administrator with a form or other instructions on how to notify the plans? How often should such communication occur?

All in all, this makes MSA self-administration even more difficult.

Tower does its best to help clients and partners navigate CMS changes. Our Chief Compliance Officer, Dan Anders, is available to answer questions and discuss how these updates affect you. Contact him at daniel.anders@towermsa.com.

Carisk® Partners, Tower MSA Partners, and Ametros to Provide Patient-Centered Case Closure and Settlement Solution in Workers’ Compensation

October 12, 2021

Carisk, Ametros & Tower logs for Case Closure

Carisk^® Partners, a specialty risk transfer and care coordination company, Tower MSA Partners, a settlement-focused MSP compliance company, and Ametros, a post-settlement medical administration company, are launching a novel, patient-centered case closure and settlement solution. The integrated program provides continuity in care and accurate medical cost projections while improving the settlement process for injured patients and workers’ compensation payers.

“We’re excited to partner with industry leaders Tower and Ametros on this innovative program that extends the trusted relationship built with the patient in our Pathways™ 2 Recovery program,” says Carisk CEO Joseph Berardo, Jr. “This bundled program benefits all parties by ensuring an accurate, fair and acceptable settlement and post-settlement experience for the patients we are entrusted to serve.”

As the patient approaches achievement of their care plan outcomes and goals, the Case Closure and Settlement Program introduces patient settlement resources delivered by Tower and Ametros into the Carisk Pathways™ 2 Recovery (P2R) process.

“Tower identifies all the treatment and legal barriers to settlement,” said Tower CEO Rita Wilson. “With the payer’s authorization, we proactively apply interventions to resolve pharmaceutical, medical, legal, and jurisdictional issues before we prepare a Medicare Set-Aside. This yields appropriate future care for workers’ comp patients, complies with the Centers for Medicare and Medicaid’s review policies, and facilitates closure. We are thrilled to overlay our settlement-focused workflow with Carisk and Ametros to create win-win outcomes for both payers and patients.”

Ametros advocates for Carisk patients during and after the settlement process, educating them about the multiple benefits available through professional administration of their MSA.

“Our mission is to help the injured person live a better life after they accept a settlement with an MSA. In addition to paying bills from their MSA, providing discounts on their treatments, and completing required CMS reporting, we have a Member Care Team to help them navigate the health care system after settlement every step along the way,” said Ametros CEO Porter Leslie.

This comprehensive solution extends patient advocacy for workers’ compensation patients whose cases Carisk manages during and after their claims settlements by ensuring that their future medical expenses are accurately covered and that the patients receive on-going support post-settlement. Working together, our Case Closure and Settlement Program accelerates claims closure, reducing payers’ claims portfolios, adjuster burdens, along with their medical, pharmacy, and indemnity costs.

To learn more, please contact Kristine Dudley, Tower’s Chief Operating Officer, at (888) 331-4941 or Kristine.dudley@towermsa.com.

About Carisk Partners and Pathways™ 2 Recovery

Carisk is a specialty risk transfer, care coordination company serving insurers, government entities, self-insured plan sponsors, and other managed care organizations. With a foundation in behavioral health, Carisk’s end-to-end combined solutions include risk-transfer and care coordination of delayed recovery, complex catastrophic cases and MBHO services. Carisk’s Pathways™ 2 Recovery program guarantees to improve outcomes and reduce overall cost of quality care by applying best practices and a patient-centered approach to manage complex challenges for the Group Health, Casualty and Auto markets. Carisk is the first and only Managed Behavioral Healthcare Organization with dual accreditations from both the National Committee for Quality Assurance (NCQA) and the Accreditation Association for Ambulatory Healthcare, Inc. (AAAHC). Visit www.cariskpartners.com to learn more.

About Tower MSA Partners

Based in Delray Beach, Florida, Tower MSA Partners provides MSP compliance and MSA services nationally. The company leverages the latest technology to seamlessly integrate, automate, measure, and manage every process from Section 111 reporting, conditional payment resolution and MSA optimization through claim closure and settlement. Tower is a nationally certified Women’s Business Enterprise (WBENC) and has received its SOC2 Type II attestation. For more information, visit https://towermsa.com/ and https://towermsa.com/blog/.

About Ametros

Ametros is the industry leader in post-settlement medical administration and a trusted partner for thousands of members receiving funds from workers’ compensation and liability settlements. Founded in 2010, Ametros provides post-settlement medical management services with significant medical and pharmacy discounts along with automated payment technology and Medicare reporting tools. Headquartered just north of Boston in Wilmington, Massachusetts, Ametros may be reached at 877.275.7415 or via www.ametros.com

Build a Better Tower: Partnerships Speed Settlements of Workers’ Comp Claims with Medicare Set-Asides

March 15, 2021

People sitting around conference table discussing MSA settlements.

Tower MSA Partners knows our strengths. And we know our business.

We’re in the Medicare Set-Aside settlement business. Everything we do, we do to make workers’ compensation settlements possible — whether they have MSAs or not. Tower has built its business processes and technology around making settlements easier, faster, smoother, and less expensive.

We recognize that the value of an MSA is its ability to facilitate workers’ compensation and liability claim settlement and closure. We also recognize that MSAs can become stumbling blocks to injured workers and their attorneys when it comes to settling claims. Since Tower’s goal is to break through all barriers to settlement, we formed a strategic partnership with Ametros, the leader in the professional administration of Medicare Set-Asides.

Helping Injured Workers Settle Well

Ametros, which does not produce MSAs, helps injured individuals manage their Medicare Set-Asides and medical allocations after settlement. During the settlement process, its team educates injured workers and their attorneys on their responsibilities and the resources available to them through professional administration after the settlement. Ametros frequently attends mediations and settlement conferences to help educate all parties on the post-settlement reality of managing a Medicare Set-Aside and how its services support compliance with Medicare Secondary Payer guidelines.

CareGuard, Ametros’ professional administration service, helps injured individuals navigate the healthcare system after settlement. CareGuard Members receive significant discounts for their injury-related medical and pharmacy expenses, durable medical equipment, home health care, and other services. Ametros handles the payment of all medical bills from their settlement funds and takes care of the Medicare reporting associated with an MSA.

Once injured workers understand they can have these services after they close their claims, they’re more likely to move forward to settle the case.

Many of Tower’s clients already work with Ametros and understand the value they bring. This made the idea of working with Ametros to simplify the settlement process for clients and adjusters a natural evolution.

Taking Work Off the Adjuster’s Desk

To further boost efficiency, Tower and Ametros developed a real-time electronic data interchange (EDI) to exchange MSA, CMS, and settlement data. MSA information is automatically updated directly in Ametros’ system at the time of MSA delivery to the client, enabling the Ametros team to begin educating the injured worker, their family, and attorneys.

This is another way we take work off adjusters’ desks and accelerate settlements that involve MSAs.

Speed Settlements

Recently, Tower launched a new program with Ametros to speed settlements. Using our powerful data analytics capabilities, Tower identifies claims that meet criteria for closure and creates a settlement candidate report. Ametros is then engaged to reach out to these injured workers or their attorneys to offer professional administration as an added benefit and to gauge interest in settlements.

When settlement is indicated, Tower prepares the MSA, executes all cost-mitigation strategies and postures the claim for closure.

This is an exciting new way to proactively address claims that may have slipped out of view and generate interest in settling. There’s no extra work for adjusters and no cost for the payer until a claim is ready to settle and an MSA is prepared.

Future posts will share other strategic partnerships that Tower has forged to build a better, stronger Tower to help you efficiently and cost effectively settle claims.

Meanwhile, have Tower create an MSA settlement candidate report for you. To learn more, contact Hany Abdelsayed hany.abdelsayed@towermsa.com (916) 878-8062.

Rita Wilson

Chief Executive Officer

Related:

Legacy Claim Settlement Initiatives

WorkCompCentral Explains the PAID Act

January 4, 2021

Red Medicare button on a keyboard to illustrate Medicare conditional payment.

The recently enacted PAID Act fixes long-term annoyances for MSA companies in securing accurate information about beneficiaries’ Medicare Advantage prescriptions drugs plans.

Right now, the Centers for Medicare and Medicaid Services (CMS) can tell payers which workers’ compensation claimants are Medicare beneficiaries. However, the agency has historically said that privacy concerns prevent it from sharing which Medicare Advantage Plans or Prescription Drug Plans these beneficiaries have joined. This means Medicare Set Aside (MSA) companies and insurers have to ask claimants or their attorneys and the information was sketchy at best, leading to conditional payment demands – and some lawsuits – post settlement.

In mid-December, the Provide Accurate Information Directly (PAID) Act was passed and signed into law, enabling Medicare to respond to queries by providing the name and address of beneficiary’s Medicare Advantage or prescription drug plans. The law should help end years of aggravation over Medicare Advantage Plan identification, according to Tower MSA Partners’ Dan Anders, who was interviewed for WorkCompCentral’s article on the law: Medicare Set-Aside Firms Applaud Passage of PAID Act Provisions.

PAID Act Becomes Law

WEBINAR – Grasp Success in Settling Work Comp Cases

October 28, 2020

banner promoting Tower webinar on settling work comp cases

Seeking the formula for success in settling work comp cases with Medicare Set Asides (MSAs)? We’ve got you covered.

A Chinese proverb says, “The temptation to quit will be greatest just before you are about to succeed.” For workers’ compensation practitioners case closure represents success. However, the impediments presented by the need for an MSA to close a case often are a temptation to quit when success is within your grasp.

On Thursday, November 18 at 2:00 PM ET, Tower’s Chief Operations Officer, Kristine Dudley and Chief Compliance Officer, Dan Anders, will be joined by special guest, Nicole Chapelle, VP of Settlement Solutions for Ametros, to provide the formula for success in settling work comp cases with MSAs.

Here’s just some of what you will learn:

The latest on ways Medicare makes CMS MSA approval difficult or drives up MSA costs and how to meet these challenges.

Straightforward clinical interventions and case settlement strategies which reduce the MSA amount and allow for quick CMS MSA approval.

Easing the settlement concerns of the injured worker by transitioning to MSA professional administration or self-administration assistance for future medical care.

You will also learn that all of this can be done without increasing your work in successfully resolving the case.

A Q&A session will follow the presentation. Please click the link below and register today!

Dan Anders in WorkCompWire: Getting Real Value Out of Your Medicare Set Aside

CMS: Indemnity Only Settlements are Not Reportable

September 1, 2020

3 blocks reading CMS to illustrate guidance on indemnity only settlements

Payers do not need to report indemnity only settlements (no release of medicals) through Section 111 Mandatory Reporting because they are not considered a Total Payment Obligation to Client (TPOC). This reporting question that had long plagued/confused workers’ compensation payers.was recently clarified by CMS during the Q & A portion of the Section 111 NGHP Webinar.

Background

Since the initiation of Section 111 reporting, Responsible Reporting Entities (RREs) have been uncertain whether indemnity only settlements are reportable and have made their own decisions about reporting these settlements. Part of the confusion arose from the definition of TPOC in Section 6.4 of the Section 111 User Guide which states TPOC:

refers to the dollar amount of a settlement, judgment, award, or other payment in addition to or apart from ORM [Ongoing Responsibility for Medicals]. A TPOC generally reflects a “one-time” or “lump sum” settlement, judgment, award, or other payment intended to resolve or partially resolve a claim. It is the dollar amount of the total payment obligation to, or on behalf of the injured party in connection with the settlement, judgment, award, or other payment.

There is nothing in this definition of TPOC which refers to a release of medicals. If anything, the references to “apart from ORM” and “partially resolve a claim” imply that indemnity only settlements are reportable. It seems if CMS added the words, “released medicals or has the effect of releasing medicals” to the definition, it would clarify any remaining uncertainty as to the types of settlements reportable to CMS.

Practical Implications

While most of CMS’s presentation were reminders of reporting rules which have been in place for quite some time, the statement regarding indemnity only settlements will hopefully clarify for RREs that a release of medicals is necessary to trigger TPOC reporting. Additionally, we hope that CMS’s webinar statement results in an update to the definition of TPOC in the Section 111 User Guide.

If you have any questions, please contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

WorkersCompensation.com’s Coverage of the Pharmacy/Legacy Claims Webinar

June 1, 2020

“The older the claim, the higher the costs—especially for prescription drugs,” wrote WorkersCompensation.com’s Nancy Grover, in this excellent recap of A Prescription for Settling Legacy Claims webinar.

The May 19 webinar was presented by Dan Anders, Tower MSA Partners’ Chief Compliance Officer, and Phil Walls, Chief Clinical and Compliance Officer of myMatrixx.

They said that aging claims increase the likelihood that the injured worker may become a Medicare beneficiary. “That means those higher drug costs must be included in a Medicare Set-Aside,” she wrote.

The fast-paced webinar explains how and why prescription drug costs increase during the life of a claim. Brand name drugs, compounds (yes, still), and “prescription cascade” (prescribing new meds to address the side effects of other meds) top the list of cost-drivers.

To gain CMS approval of an MSA, medications that may not be needed or even being used must be allocated in the MSA. What’s more, they are priced at Redbook’s lowest average wholesale price (AWP), eliminating discounts the pharmacy benefit manager (PBM) once provided. Side note: Phil describes issues with AWP in detail during the Q&A at the end of the webinar.

Dan and Phil discussed ways an MSA provider and PBM can partner to identify and address unnecessary costs—without negatively impacting the injured worker’s treatment. “We reach out to the treating physician for last dates of service to see what’s going on,” Dan said. “We also do drug reviews to see if there are alternatives that can be implemented.”

Presenters cited a case where an intervention reduced the total morphine equivalent dosage from a dangerous 480 mg per day to 120 mg per day. The changes produced a savings of about $1 million.

“Our goal is never to keep the injured worker from obtaining the therapy they need, but not to expose them to unnecessary prescribing,” Phil said.

To download the recording of this valuable webinar, please go to: https://register.gotowebinar.com/recording/7163259288372148492

Tower MSA

Category: Workers Compensation