Medicare Set-Aside (MSA)

Addressing cost drivers and barriers to claim closure and smoothing the path to CMS approval and settlement.

SCHEDULE A CONSULTATION

Identification

Pre-MSA Triage

Physician Peer Review

Clinical Oversight

MSA 2nd Opinions

Physician Follow Up

MSA Cost Savings
From Clinical
Intervention 0%

CMS Approved
MSA Dollar
Amounts 0%

CMS Approved
MSAs with $0 RX 0%

CMS Re-Review
Success Rate 0%

FEATURES & BENEFITS

Identifies MSA exposure
Addresses cost drivers and inappropriate care prior to the MSA
Optimizes patient care
Reduces MSA cost
Positions for CMS approval
Availability of a Non-Submit MSA

Our process includes:

Determine whether an MSA is appropriate
- Start with Tower’s “Do I Need a WCMSA?” decision tree
- Turn to personalized and case specific consultation from Tower experts
- Use Online Referral for quick MSA referral
Perform Pre-MSA Triage
- Analyzes medical and pharmacy records
- Identifies cost drivers and barriers to settlement, such as high drug spend, opioids, ambiguous medical treatment recommendations
- Recommends clinical interventions
Conduct Interventions
- Physician Follow Up to clarify treatment ambiguities
- Work with the physician to modify treatment and inappropriate drug regimens
- Clinical Oversight to monitor drug tapering and other treatment changes
- Confirm discontinuation of inappropriate medications
- Document evidence of current treatment (Rx Drug Review, Physician Follow Up, Physician Peer Review, Clinical Oversight)
Prepare/submit MSA to CMS
- Monitor approval progress
- Review, advise and respond to CMS Development Letters, if any
- Automatic re-review request upon identification of CMS error
- Deliver CMS-approved MSA

SCHEDULE A CONSULTATION

INTEGRATED INTERVENTION PLATFORM SIMPLIFIES ADJUSTER EXPERIENCE

CASE STUDY: CMS Re-Review

CMS-Re-Review

Challenge

CHALLENGE

Tower submitted an MSA to CMS for a projected allocation of $16,223.71 but received a counter-higher of $221,882.00. Tower’s reconciliation team evaluated CMS’s MSA determination and found that CMS had included the medication Lyrica 50mg and 70mg, adding $205,286.40 to the MSA.

Solution

SOLUTION

While there was no dispute the claimant took Lyrica at the dosages allocated, Tower submitted that the prescription for Lyrica to treat a foot crush injury was a non-Medicare covered use for Lyrica.
Accordingly, Tower used the CMS MSA Re-Review process to submit a request that Lyrica be removed from the CMS-approved MSA. In response, CMS stood by its position that Lyrica is considered “Medicare-covered” under their guidelines.
Tower believed this was clearly an incorrect interpretation by CMS of its own Medicare coverage guidelines and escalated the request to senior CMS management for review.

Result

RESULT

On further review, CMS agreed that Lyrica prescribed for a crush injury to the foot is not a medically accepted indication and would not be covered by Medicare. Lyrica was removed from the allocation resulting in case settlement.
While CMS agreed Lyrica use for a foot crush injury was non-Medicare covered, in an update to its WCMSA Reference Guide, CMS advised Lyrica will be allocated in the MSA when such use stems from spinal cord neuropathy, a use previously considered non-Medicare covered.

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CASE STUDY: MSA Optimization

PDF Case Study MSA Optimization

Challenge

CHALLENGE

Tower was engaged to prepare an MSA for a 54 year old partial quadriplegic. The lack of current medical records, the erratic behavior of the patient, the quality of the provider’s treatment coding, and unknown treatment outside of the WC Plan were challenges to preparing an accurate MSA. The preliminary MSA amount was $424,528.

Solution

SOLUTION

In review of the treatment records, Tower’s medical experts were able to identify several instances where Medicare covered expenses could be reduced as part of Tower’s Optimized MSA process. At Tower’s request, the client obtained current medical records. Tower’s clinical team reviewed those records and the corresponding billing codes used for all treatments. By analyzing the provider’s treatment methods against Medicare’s reimbursement requirements, Tower was able to identify items that were more accurately priced with alternative codes. One instance identified was a determination that a catherization code (A4353) was used incorrectly. By using the correct billing code and applying other cost savings strategies to the treatment regimen, the MSA dollars were significantly reduced. To ensure that CMS would accept the updated medical coding, Tower detailed how the original billing code was incorrectly used and then provided the correct coding.

Result

RESULT

Upon finalization of the optimized MSA, a total allocation amount of $248,661 was submitted to CMS for review and approval. CMS accepted the proposed MSA amount and responded with a Full Approval. Using Tower’s proprietary processes and technology, the client carrier was able to reduce the Medicare exposure of this settlement resulting in total savings of $175,867.

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CASE STUDY: MULTIPLE SUBSCRIBER/OFF LABEL DRUGS

Info graphic Multiple Subscriber Off Label Drugs Case Study

Challenge

CHALLENGE

Claimant sustained industrial injury to head and neck in 2009. Diagnoses at the time of MSA preparation included concussion, headache, anxiety and depression.

Solution

SOLUTION

With client approval, Tower's clinical team initiated a Physician Peer Review to determine the appropriateness and necessity of the prescription drug regimen.

Result

RESULT

Through its Clinical Oversight Service, Tower contacted both psych and neuro physicians to monitor the weaning process. With each change in drug therapy, previous drugs were blocked with the PBM.

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CASE STUDY: PHYSICIAN PEER REVIEW

Infographic of Physician Peer Review Case Study

Challenge

CHALLENGE

Chronic pain associated with cervical injury. Patient had multiple surgeries with current treatment consisting of Oxycontin 60 mg (4/day), Oxymorphone 10 mg (4/day) coupled with antidepressant, NSAID, muscle relaxant and insomnia treatment. At time of MSA preparation, total morphine equivalent dosage = 480 MED / Day and the total MSA projection = $1,234,551.

Solution

SOLUTION

Through its Clinical Intervention Module, Tower’s clinical team initiated a Physician Peer Review to assess the appropriateness of the prescription drug regimen for the injured worker. The reviewing physician then engaged the pain management physician in a discussion regarding symptoms and behaviors associated with opioid addiction and recommended alternative treatment options to reduce MED (morphine equivalent dosage) of 480mg / day. Written agreement to wean the patient from both short and long acting opioid medications was obtained.

Result

RESULT

MED was reduced to 120 mg / day and all side effect medications were discontinued. MSA allocation was reduced to $185,872 and submitted to CMS. In its review, CMS accepted Tower’s documentation of successful weaning and discontinuation, but increased the number of fills for the muscle relaxant, Tizanidine. CMS approved with a slight counter higher of $210,641.

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CASE STUDY: PRE-MSA TRIAGE

Pre-MSA Triage Case Study

Challenge

CHALLENGE

Case submitted to Tower for Pre-MSA Triage to assess Medicare exposure. In 2010, worker was doing electrical line work when he was struck by lightning. Injuries included electric shock with pain, insomnia, depression and seizure activity. Treatment included prescription drugs as follows: Hydrocodone/APAP (7.5 / 325 mg at 4 / day), Baclofen (muscle relaxant), Topamax (anti-seizure), Cymbalta (antidepressant), Keppra (anti-convulsant), Naproxen (pain), Clonazepam (anti-anxiety).

Solution

SOLUTION

As part of the standard Pre-MSA Triage process, Tower’s clinical team identified the key cost drivers, made recommendations within the context of the state of jurisdiction to optimize the drug regimen, documented recommendations to achieve the desired result, and calculated the optimized MSA value at $641,930. In this case, recommended next steps included Tower’s Physician Follow Up service to contact the injured worker and treating physician to request a change from ‘Brand’ to ‘Generic’ formulation for Topamax and Keppra.

Result

RESULT

With client approval, Tower used the information prepared with the PreMSA Triage, added the attestations obtained from both injured worker and physician noting that substitution was allowed for both Topamax and Keppra and finalized the MSA for submission to CMS. In its review, CMS accepted the attestations as confirmation of the change in drug therapy and approved Tower’s submitted MSA at $641,930.

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CASE STUDY: Re-Review MSA

re-review-msa case study PDF

Challenge

CHALLENGE

Tower submitted a $0 MSA based upon a Tower-obtained treating physician’s statement that the work-related right shoulder rotator cuff sprain had completely resolved with no need for future medical care. CMS responded with a $17,729 counter-higher to include annual orthopedic visits, multiple primary care physician visits per year, diagnostic testing, physical therapy and Norco.

Solution

SOLUTION

A Re-review was submitted to CMS based on records obtained from the claimant’s primary care physician which documented that Norco was being prescribed for an unrelated low back condition. Further, besides reasserting the treating physician’s statement confirming the work-related right shoulder sprain as resolved, it was also highlighted to CMS that upon claimant’s release from care there were minimal reports of pain and he was released to full duty.

Result

RESULT

CMS removed all treatment and medication from the MSA and approved the $0 allocation.
Upon receipt of a CMS MSA counter-higher, Tower’s reconciliation process provides for an automatic re-review request to CMS when a reasonable basis exists to dispute the determination. In this case, Tower’s Physician Follow-Up service followed by the re-review, was instrumental in the successful $0 MSA approval. Tower’s Physician Follow-Up service, as well as MSA re-reviews, are provided at no charge when initiated as part of the MSA and CMS submission process.

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"Tower MSA Partners is a true Medicare compliance partner for Acuity Insurance. This includes automating Section 111 Mandatory Reporting, coordinating conditional payment disputes and appeals with our internal compliance team and preparing MSAs which settle cases. They truly understand our business model!"

Nancy Schulz – Director, Managed Care
Acuity Insurance

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