Posted on May 14, 2021 by Tower MSA Partners
According to the American Nurses Association (ANA), May is Nurses Month, dedicated to honor, thank, and support nurses and all those in the nursing profession. They’ve designated the 2021 theme as “Nurses Make a Difference.” Plus, ANA joins the World Health Organization (WHO) and global colleagues in extending the Year of the Nurse into 2021.
Tower Nurses Make a Difference
We couldn’t agree more with the sentiment that nurses make a difference, and we join in the salute. At Tower, nurses are an integral part of our team. RNs, who hold the Medicare Set-Aside Consultant Certification (MSCC), prepare Medicare Set-Asides (MSAs). Tower nurses review, analyze and summarize medical records and allocate care based upon Tower’s clinical standards, evidence-based medicine, and CMS MSA guidelines.
Their scrutiny often turns up gaps in care, open-ended treatment, treatment of unrelated body parts, discontinued or inappropriate prescriptions, dangerous dosages, and opportunities to switch brand drugs to generics. Once our nurses identify ways to reduce costs without compromising an injured worker’s care, specific clinical interventions are recommended to our clients.
Separate from the nurse preparing the report, a nurse-led clinical quality assurance team the accuracy of the report and makes sure all cost-containment opportunities have been considered and are presented to our client delivery of the MSA report. Subsequently, clinical interventions, such as Tower’s Physician Follow-up service, work to obtain a physician statement and document the current, appropriate treatment in language that CMS can use to approve the MSA as written.
The difference our nurses make can be measured in Tower’s key performance indicators, which reveal a median CMS-approved MSA of $23,205. In addition, only 40% of our CMS-approved MSAs allocate for prescription medications, and 83% of them are approved without post-submission development letters. This record of success would be impossible without the dedication of our nurses. Thank you!
Nurses Month: Stories from the pandemic frontlines
Beyond our gratitude for the nurses on our own team, for Nurses Month, we pay tribute to nurses everywhere and in every role. Nurses have been everyone’s lifeline during the pandemic but have paid a toll for the crucial role they played. We’ve compiled some stories about the experience of nurses over the past year that we found noteworthy.
What Nurses Want You to Know About the Past Year – In this article for AARP, Michelle Crouch gathers nurses’ reactions to the past year. Nurses say that the sheer number and pace of coronavirus fatalities was overwhelming; keeping families apart was painful; mourning patients who died was painful; fear for their own and their family’s safety was a constant backdrop. They are emotionally and physically exhausted. How can we best thank and support them?
“The best way the public can support nurses right now is to get one of those vaccines, nurses say. “Please, go and get vaccinated,” Carrell-Yoder stresses. “We don’t want to do this again. We don’t want more people to die.”
“All Hands On Deck”: The COVID-19 Pandemic Through Nurses’ Eyes – The Dose Podcast from Shanoor Seervai for the Commonwealth Fund looks at the experience of frontline nurses one year into the pandemic, with many experiencing stress, grief, and fatigue. Her guest is Mary Wakefield, a nurse and a professor who has held positions in the Obama administration and in the Biden-Harris transition team. When asked about lessons learned for going forward, Wakefield said:
” … our public health infrastructure, as many people recognize clearly now, is incredibly anemic. The largest proportion of public health workforce is comprised of nurses, and yet they’re still too few. We’ve seen an erosion in the United States public health infrastructure over the last number of years. That has got to be built back up. We need more public health nurses. Not the same, we need more.”
Nursing in the time of COVID-19: Two advanced practice nurses on the front lines of the pandemic – Johis Ortega and Juan M. González are advanced practice nurses and professors at the University of Miami’s School of Nursing and Health Studies. Ortega also serves as Associate Dean for Hemispheric and Global Initiatives at the school and González is Director of the Master’s Program in Family Nursing. In a story for the Pan American Health Organization (PAHO), they offer a portrait of their experience in treating patients in the peak of the pandemic.
It’s Always Been Tough Being A Nurse. Now It’s Worse – Tom Lynch of Workers Comp Insider tells us that nurses experience a shockingly high level of on-the-job injuries, including the highest rate of sprains and strains of all professions. And he says that:
“The COVID-19 pandemic has made things even worse. A new Washington Post – Kaiser Family Foundation Poll reveals roughly three out of ten health care workers are considering leaving the profession and more than half report being “burned out” due to the overwhelmingly horrific year they’ve just spent trying, and often failing, to save the lives of COVID inflicted patients.”
Posted on May 11, 2021 by Tower MSA Partners
With a name like “Mandatory Insurer Reporting” and potential reporting penalties of up to $1,000 per day per injured worker, one would think payers would take Section 111 reporting pretty seriously. But since these penalties have never been enforced, avoidance of penalties has not been a top concern.
It looks like penalties could be coming soon, though. The Centers for Medicare and Medicaid Services (CMS) positioned itself to implement them by proposing specific regulations last year. The agency solicited comments from stakeholders last April and could publish final regulations at any time.
Tower’s Chief Compliance Officer, Dan Anders, wrote an article in this week’s WorkCompWire Leaders Speak series, Plan Now to Avoid Pending Medicare Reporting Penalties, that recaps the history of Section 111 reporting and outlines reporting errors and CMS’s proposed penalties. And, unlike many articles that just tell you what CMS says, Dan’s piece recommends ways readers can steer clear of potential errors and problems.
Speaking of steering clear, if you’re not already using Tower’s S111 Management Dashboard, ask Hany Abdelsayed to take you for a test drive. Contact Hany at email@example.com or 916-878-8062.
For more details on Section 111 reporting and Civil Money Penalties, check out Dan’s prior posts:
- CMS Section 111 Mandatory Insurer Reporting Webinar Recap
- CMP Comments Submitted
- CMS Issues Proposed Rule for Mandatory Insurer Reporting Penalties
You can always contact Dan with any questions or concerns about this or any other compliance or MSA issues. He can be reached at firstname.lastname@example.org.
Posted on April 28, 2021 by Tower MSA Partners
In our unwavering commitment to data privacy and security, Tower MSA Partners has completed its SOC 2 Type II audit. The SOC 2 Type II audit reports on a service organization’s non-financial reporting controls and processes as they relate to the Trust Services Criteria developed by the American Institute of Certified Public Accountants (AICPA). It tests the organization’s controls related to security, availability, processing integrity, confidentiality, and privacy over an extended period of time.
From the beginning, Tower has been committed to technology driven processes to bring efficiency and measured results to our clients. The SOC 2 Type II attestation demonstrates how our corporate governance effectively assesses and manages risks and ensures the integrity of the systems and processes delivered by Tower and its business partners to execute the same high level of protection throughout the supply chain. I’m extremely proud of this leadership team and its accomplishments.
Conducted by KirkpatrickPrice, the audit verified the fairness of the presentation of management’s description of the service organization’s system and the suitability of the design and operating effectiveness of the controls to achieve the related control objectives included in the description throughout a specified period.
“Tower delivers trust-based services to their clients, and by communicating the results of this audit, their clients can be assured of their reliance on its controls,” said KirkpatrickPrice President Joseph Kirkpatrick.
Related Prior Posts:
Posted on December 29, 2020 by Daniel Anders
Business Insurance’s Louise Esola wrote a nice piece, quoting Tower’s Chief Compliance Officer, Dan Anders, explaining how a new law will make it easier for workers’ compensation and liability insurers to determine if Medicare eligible claimants are or were members of Medicare Advantage and Part D Rx Drug Plans. See https://tinyurl.com/BIPAIDAct.
Posted on October 28, 2020 by Tower MSA Partners
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 WC 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!
Posted on October 12, 2020 by Tower MSA Partners
In today’s digital environment, if you are an employer, carrier or TPA, you are likely inundated with data. You get claims data, medical and pharmacy data, predictive analytics, benchmark performance data, claim reports, drug interaction, duplicate therapy and contraindication notices, even drug triggers like poly-pharmacy notices, opioid utilization reports, and morphine equivalent dosage (MED) outliers. You digest voluminous amounts of data internally and also receive a plethora of reports from your vendor partners. With access to so much data, how do you aggregate it into its simplest form, drilling down to the information that actually shows how you’re doing? Whether you call it ‘key performance indicators”(KPIs) or use some other business term, the short answer is “metrics.”
In the words of Peter Drucker, “You can’t manage what you don’t measure.”
As a company that deals with volumes of data internally, and as we work to support our clients’ efforts to comply with the MSP statute, Tower is all about metrics and continuous improvement. Metrics drive internal efficiency improvements, workflow changes to streamline processes and the implementation of technology enhancements to improve our work product and turnaround times. It’s also how we bring added value to clients to optimize MSA outcomes. We define, measure and manage the metrics that yield the ”best” balance in care, cost, and compliance and we use these key performance indicators to reverse engineer MSA preparation methodology to continuously improve MSA, CMS approval and settlement outcomes. We identify the metrics that drive the results we want to see. We then measure our performance and modify processes, workflow, and technology to improve.
METRICS TELL A SIMPLE STORY
Step #1 is to identify what drives the results you seek to achieve. For example, in the case of the MSA and settlement, most would agree that pharmacy is the single biggest cost driver. We’ve heard this from clients through the years and we’ve monitored this issue ourselves. Though prescription drug costs have come down over the past year, pharmacy remains the biggest concern expressed by payers when settling claims that involve an MSA. Yet if asked, would you know what percent of your CMS approved MSAs include opioids, the percent of MSAs that include any pharmacy, or the average cost of prescription drugs on MSAs. You can manage (improve) only what you are measuring.
Measuring 2019 performance in Tower’s total book of business as it relates to CMS approved MSAs and pharmacy costs,
57% of CMS approved MSAs with ongoing medical had $0 allocated for pharmacy;
78% of CMS approved MSAs with ongoing medical had $0 allocated for opioids.
We know what drives the results we want to see and we know where we are today. We’ve measured these metrics for the past 3 years, and continue to monitor to see how we can improve.
ONCE YOU MEASURE, HOW DO YOU MANAGE?
Tower’s clinical staff constantly examines current CMS performance against the latest state workers’ compensation statutes and associated fee schedules, then overlay this with CMS’s review methodology as defined in the most current WCMSA Reference Guide. When changes are found, updates are immediately loaded into our system, verified and released. Getting this process in place took a great deal of time, effort, and technology support, but it was key to our ability to measure performance. Once in place, it’s now a simple verification, audit and sign-off process each month.
In addition to monitoring external changes, our system also benchmarks every CMS response against our internal best practices in MSA allocation. This is done by reconciling every line item in every CMS response. Through this software module, we know exactly how we perform against CMS in pricing, frequency, life expectancy, etc. This information is stored in real time for every response every day, not via a month-end report or only when there’s a Counter Higher response. Our system prompts our staff to review and reconcile each CMS response immediately upon upload.
Through our proactive approach to clinical and pricing methodology and our CMS response measurements, we avoid overfunding when we initially draft the MSA. We are also able to reverse engineer to identify cost drivers and barriers to settlement as part of case triage. We know which clinical and legal interventions can mitigate exposure because we have the historical benchmarks that measure these results historically.
In tracking CMS results over the past 3 years, CMS MSA dollars continue to go down through consistent execution of Tower’s pre-MSA intervention / physician contact process
In 2019, our pre-MSA intervention model yielded CMS approved MSA savings of 53.3% when initiated before CMS submission.
We’ve also identified the documentation/evidence CMS requires in order to approve changes in medical treatment and reductions/discontinuations in drug therapy and we obtain this up front.
With historical benchmarks and CMS performance data, we can easily discern when we have a basis to challenge CMS via re-review submission, and we know what clinical, statutory and pricing documentation to provide to support our request. In measuring our CMS re-review performance for all CMS counter higher responses received in 2019,
Average turnaround time for Re-review determination and submission was <48 hours and CMS Re-review success rate was 68%.
WHAT DOES THIS MEAN TO YOU?
When evaluating MSP partners, check out their numbers. Find out:
- Their success rates for clinical interventions and the average dollars saved because of those interventions;
- The number of Medicare conditional payment searches and investigations initiated and their success rates for disputes and appeals, including total dollars saved;
- How many Medicare Advantage plan searches and investigations they’ve conducted;
- A breakdown of the percentage of CMS MSA approvals, counter-highers and counter-lowers;
- Percentage of counter-highers submitted for re-review and their success rate.
- How they leverage Section 111 data to improve accuracy with conditional payments and MSAs.
COMPLIANCE BY THE BOOK, CLOSURE BY THE NUMBERS
If the above resonates with you, I encourage you to check out our website. We’ve redesigned the site to better reflect our commitment to MSP compliance solutions, not just services. Throughout the site, you’ll see metrics like those above, as well as many other key performance indicators that we use to measure performance, manage improvements and optimize outcomes. You’ll also see specific case studies that demonstrate the successes achieved with MSAs, conditional payment negotiations, physician follow up and clinical interventions, as well as what our clients have to say about working with Tower.
For questions, or to learn more about how Tower is Measurably Better, please email us at email@example.com or call us directly at 888.331.4941.
Posted on September 23, 2020 by Tower MSA Partners
This Thursday, September 24 at 1 p.m. ET the Centers for Medicare and Medicaid Services (CMS) will be hosting a Commercial Repayment Center NGHP Applicable Plan appeals webinar.
According to the notice:
CMS will be hosting a CRC NGHP Applicable Plan webinar to review the procedures and best practices for redeterminations. The format will be opening remarks by CMS followed by a presentation from the CRC. This webinar will primarily focus upon how to effectively submit a redetermination request (sometimes called a first level appeal). During the presentation, we will also be reviewing appeal requirements, what is and is not subject to appeal, and details about what documentation is needed to support the appeal request in various situations.
We encourage anyone involved in Medicare conditional payment appeals stemming from demands from the CRC attend the webinar.
Slides and Q&A Available from August Reporting Webinar On another note, the slides and Q&A from CMS’s August 13, 2020 Section 111 Non-Group Health Plan (NHGP) Reporting webinar are now available. Tower provided a summary of this webinar in a prior article entitled CMS: Indemnity Only Settlements are Not Reportable.
Posted on September 22, 2020 by Tower MSA Partners
The National Alliance of Medicare Set-Aside Professionals (NAMSAP) is the leading educational organization on Medicare Secondary Payer compliance. Its annual conference, which is sponsored by Tower, brings together the best minds in the industry, including representatives from CMS and its contractors, for presentations and discussions on the latest in Medicare compliance and MSAs.
Tower’s Chief Compliance Officer and Vice President of NAMSAP, Dan Anders, Esq., is a panelist for the session Reference Guide Lesser Known Facts and Fallacies.
This year’s virtual conference, which will be held October 6 and 7, provides a unique opportunity to learn from these professionals from the comfort of your home office. We encourage anyone who is involved with MSP compliance on a regular or semi-regular basis–or is just interested in learning more–to attend. Attendees can earn continuing education credits, such as CLE, MSCC, CMSP and CLCP.
Find out more about the conference here.
If you are interested in attending the virtual conference or have additional questions, please contact Dan Anders at firstname.lastname@example.org or (888) 331-4941. We hope you can attend!
Posted on September 1, 2020 by Tower MSA Partners
Tower MSA Partners has created an intuitive, easy-to-use dashboard to help you avoid CMS’s penalties for non-compliance with Section 111 reporting. Once in effect, the penalties can amount to up to $1,000 per day per claimant for things like failing to accurately ORM and TPOC.
Our new dashboard provides 24/7 access to your claims data and reporting oversight for all aspects of the reporting process. It will even remind you to update ORM Term Dates when claims settle. You can run all kinds of reports and correct errors on the fly.
Posted on September 1, 2020 by Tower MSA Partners
During the Q & A portion of the recent Section 111 NGHP Webinar, CMS finally clarified a reporting question that had long plagued/confused workers’ compensation payers. Payers do not need to report indemnity only (no release of medicals) settlements through Section 111 Mandatory Reporting because they are not considered a Total Payment Obligation to Client (TPOC).
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.
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.email@example.com or 888.331.4941.
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