Category: Workers Compensation

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. 

Related:

CMS: PAID Act Implementation Guidance & New ORM Termination Option

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!

Register Now
 
Related:
 
 

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.

 

Other Webinar Topics

While the above was the most notable takeaway from the webinar, CMS also:

  • Highlighted the RREs responsibilities when changing reporting or recovery agents.
  • Reminded reporting entities of the importance of accurate reporting of diagnosis codes.
  • Reiterated the requirements for reporting the code ‘NOINJ’ in liability insurance. This is used when the settlement, judgment, award, or other payment releases medical or has the effect of releasing medicals, but the type of alleged incident typically has no associated medical care.
  • Indicated that while an RRE may submit multiple claim input files during the quarter, it is limited to one file submission every 14 days and not until the prior file is completely processed. This type of multiple file reporting would most commonly be done to report TPOC termination that cannot wait until the next quarterly reporting cycle.
  • Noted that the reporting thresholds remain at $750 for physical trauma-based injuries. The thresholds do not apply to claims involving implantation, ingestion or exposure.
  • Provided threshold errors, such as delete transactions for more than 5% of the total records submitted, and the top reporting errors.
  • Another reminder on the correct reporting of Med Pay and Personal Injury Protection (PIP) coverage.

Full details on the above can be found in the CMS slides and presentation notes here.

 

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

stethoscope and insurance claim form

“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 CEO Rita Wilson Talks MSAs and Metrics in WorkCompWire’s Leaders Speak

April 18, 2019

How can you use metrics to evaluate your MSP compliance and MSA programs? And, what metrics apply? Tower CEO Rita Wilson shares key performance indicators, ways payers can use them in the settlement process and apply settlement strategies to on-going claims management in this week’s WorkCompWire Leaders Speak.

Here’s a brief excerpt:

“When issues are detected, the same clinical interventions (pharmacist-to-physician contact or physician peer review) used in the MSA process can be used to ensure the injured worker receives appropriate treatment and reduce costs to the claim. Payers can mitigate their eventual MSA exposure by managing the claim for settlement, and the PBM can help, but only if they know what will happen downstream.

Some payers tend to isolate MSP compliance, but it’s actually a continuation of claims management and critical to pre-settlement analysis. If payers have a high drug spend throughout the life of the claim, they are accepting a lifetime of spend at settlement. If they implement clinical interventions to reduce pharmacy usage early in the claim, they reduce its overall costs.”

Read the full article:Rita Wilson: Applying Settlement Strategies to Improve Ongoing Claims Management

Related:

What Gets Measured Gets Managed…. What’s Your Number?

Tower MSA Partners to Sponsor Workers’ Compensation Institute (WCI) – TV

August 1, 2017

Tower MSA Partners is sponsoring WCI-TV, the televised coverage of Workers’ Compensation Institute’s Workers’ Compensation Education Conference, and is dedicating its TV segments to examining opioids.

“Tower is pleased to partner with WCI to sponsor WCI-TV for the 3rd consecutive year and participate in the interview process throughout the conference. With opioid use in the forefront of issues facing workers’ compensation payers, we will explore prescribing habits, addiction and interventions from different disciplines within the system,” said Rita Wilson, CEO of Tower MSA Partners.

Some of the perspectives and industry leaders featured in Tower’s interviews are:

  • Claims Management – Carrie Struzynski, RN, LHRM, CHRM, MSN, PhDc, Quarterback/Senior Manager, Risk Management, Safety & Insurance, Randstad North America, Inc.
  • MSP Compliance – Dan Anders, Chief Compliance Officer, Tower MSA Partners
  • Peer Review – Mark Pew, Senior Vice President, PRIUM
  • Physician – Mel Pohl, MD, FASAM, Chief Medical Officer, Las Vegas Recovery Center
  • Pharmacy Benefit Management – Phil Walls, RPh, Chief Clinical & Compliance Officer, myMatrixx
  • Public Policy – Mark Walls, Safety National’s Vice President of Communications, and Kimberly George, Senior Healthcare Advisor, Sedgwick Claims Management Services

From its studios near the exhibit hall, WCI-TV’s programming will be aired throughout the conference area, in conference hotels’ guest rooms, on shuttles, WCI’s website, e-blasts, and on You Tube. It is produced by CNTV, a Winter Park, Florida-based company that delivers a news approach to the convention television business.

The 2017 WCI WCEC will be held August 6-9 at the Orlando World Center Marriott.

The full article may be found here.

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

January 27, 2017

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

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

Rita’s comments to WorkersCompensation.com follow:

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

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

The full article may be found here.

Christmas Miracles Can Happen in Workers’ Compensation

December 23, 2016

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

Background

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

The Story as Shared by our Client

Dear Hany,

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

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

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

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

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

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

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

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