Tower News

As 2017 winds down, it seems like an appropriate time to feature some of the top content that has been provided by Leaders from the industry for our Leaders Speak section.

So, as we close out the year and prep to bring you more great thought leadership in 2017, check out the list below for our most popular Leaders Speak posts from the first half of this year (in no particular order)…

The full article may be found here.

“I start to think we are making progress and we are getting somewhere and opioid use in comp is down, and then you come across something like this,” said Alex Swedlow, president of the Oakland-based California Workers’ Compensation Institute, which conducted a study that found 70% of federally mandated and approved California workers compensation Medicare set-aside settlements for injured workers include money earmarked for decades of opioid use.

“It’s a confirmation of what we believe has existed,” said Rita Wilson, CEO and co-founder of Delray Beach, Florida-based Tower MSA Partners L.L.C., which helps insurers and employers remain Medicare-compliant and began tackling the opioids in Medicare set-asides in mid-2015. “(It) quantifies the concern of too much opioids in the Medicare set-asides,” she said of the study that was released in the fall.

The full article may be found here.

It’s the week of our industry’s biggest conference of the year. There will be a lot of great content, but be sure not to miss these 5 sessions:

• The Norstrom Way: Boosting Injured-Worker Engagement
• Steal These Ideas! Teddy Award-Winning Employers Showcase Their Successful Strategies
• The Intersection of Medicine and Disability – A Doctor’s View
• Old Dogs, New Settlement Tricks
• 60 Tips in 60 Minutes – Sage Advice for Overcoming Complex Claim Challenges

The full article may be found here.

If seeing the word opioids one more time doesn’t trigger some sort of reaction, whether sadness, anger, desperation, or possibly hope at what appears to be traction to ‘Turn the Tide’ of addiction, then I can only surmise that you must live under a rock! That certainly isn’t the case here, as in our world of MSP compliance, the word opioids is either read, spoken or written every single day. It permeates our industry and our lives.

The most recent example of the profound impact opioids continue to have on workers’ compensation, the MSP industry, and specifically on the Medicare Set Aside (MSA), came from a study released earlier this week by the California Workers’ Compensation Institute (http://www.cwci.org). Those who saw the study became painfully aware that in the state of California,

“Nearly 70% of federally mandated and approved Medicare settlements for injured workers require funding for decades of opioid use, often at dangerously high levels and in conjunction with other high-risk drugs.”

CWCI study and key findings

The CWCI examined data from 7,926 California WCMSA plans completed, submitted and approved by the Centers for Medicare and Medicaid Services (CMS) in 2015 and 2016. To achieve a representative cross section of the state’s MSA cases, the authors compiled its dataset of 7,926 WCMSAs from four national vendors whose work product represented more than 50% of the state’s MSA market.

Overall findings were as follows:

• $103,393 Average CMS approved WCMSA
• $48,986 Average RX$ (47.6% of MSA)
• 69.4% % WCMSAs with opioids (twice the rate of any other drug class)
• Norco / Vicodin were included in 44% of the opioid inclusive WCMSAs

Also significant were CWCI’s findings when the authors compared opioids found in WCMSAs to a case-matched control group of closed workers’ comp permanent disability claims for similar injuries. This comparison demonstrated that the WCMSA allocations included much stronger opioids, with average morphine milligram equivalents (MMEs) at 45 times the level used in the control group during the life of the claim. In addition, the WCMSAs with opioids required funding for an average daily dose of 54.7 morphine equivalents (MEDs) for a period of 20.9 years.

An industry’s call to action

The realization that opioids represent a major problem with the WCMSA did not come as a surprise to Tower, or to the National Alliance of MSA Professionals (NAMSAP). For the past 2 years, NAMSAP, through its Evidence Based Medicine and Data and Development committees, has been working tirelessly to educate the MSP community as to what happens in the MSA when opioids are prescribed over the life of the claim and remain as standard treatment when the MSA is prepared and submitted to CMS. NAMSAP has hosted multiple webinars to bring industry, regulatory and legislative experts together to discuss the opioid impact, and sent representatives to Washington to discuss our concerns with CMS. At our most recent annual conference, NAMSAP hosted Assistant Surgeon General, RADM Pamela Schweitzer, Pharm.D., BCACP, who shared both her concern for our situation, and her enthusiasm for our passion and our efforts.

With a singular focus among our members, I am hopeful that NAMSAP can successfully modify prescribing behavior and ultimately impact WCMSA outcomes. Unfortunately, this doesn’t benefit carriers, employers, third party administrators and injured workers today.

What are we doing now?

At Tower, the issue of opioid misuse and the importance of pre-MSA intervention has been in the forefront of our business model, our technology platform and our workflow from day 1. Our Pre-MSA Triage service identifies issues long before the MSA and provides practical recommendations to address obstacles. Our integrated technology platform tracks pharmacy triggers and interventions, escalates to our Internal Pharm. D. to contact the treating physician and diaries to track progress until treatment has been optimized. We then finalize the MSA and submit to CMS for approval.

The result of our workflow, our technology and the internal team of clinical, legal and medical experts we’ve built is a streamlined, end-to-end process that identifies issues, tracks progress and drives results for our clients.

Results achieved across all clients:

• $59,070 Average CMS approved (Non-Zero) WCMSA$
• 58.7% CMS approved WCMSAs with $0 Pharmacy
• 22.6% CMS approved WCMSAs that include opioids
• 61.4% MSA savings through integrated Rx interventions

These are numbers we track monthly through our CMS Reconciliation Module to confirm that CMS performance continues to improve. Our belief is that until prescribing habits change and best practices in opioid treatment can be implemented and enforced, our responsibility is to drive better outcomes through both formal intervention services and consultative oversight. Our clear focus is to limit pharmacy to those medications that are appropriate for long term use, to discontinue opioids where possible and to reduce MED to the lowest level possible when opioids must be included in the WCMSA.

Conclusion

In the words of HHS Secretary, Tom Price, M.D. and Kellyanne Conway, counselor to President Trump,

“Ending the opioid epidemic will require an all hands on deck effort”.

Stay tuned.

CMS issued the following brief statement on their website this week:

The Centers for Medicare and Medicaid Services (CMS) continues to consider expanding its voluntary Medicare Set-Aside Arrangements (MSA) review process to include liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS will work closely with the stakeholder community to identify how best to implement this potential expansion of voluntary MSA reviews. Please continue to monitor this website for updates and announcements of town hall meetings in the near future.

Notably, very little information provided other than stating CMS will work with stakeholders before formalizing the expansion of the MSA review process to liability and no-fault. Based upon this statement, we can assume CMS will not spring the expansion on us, but give impacted parties an opportunity to comment before a final policy is put in place. Tower MSA will provide updates when further information is released by CMS or town hall meetings are scheduled.

Benjamin Franklin must have been contemplating Medicare Advantage Plan reimbursement when he uttered one of his famous lines: “If you fail to plan, you are planning to fail.” Over the past few years Medicare Advantage plans have increasingly been seeking reimbursement for payments made stemming from workers’ compensation, liability and no-fault claims, otherwise known in Medicare circles as Non-Group Health Plans (NGHPs). Despite these increasing efforts, many NGHPs have not planned how they should respond to such reimbursement claims.

With the goal of working with our clients to educate and assist with proper planning, earlier this month, Tower MSA was privileged to have Brian Bargender, Subrogation & Other Payer Liability Business Consultant for Humana, participate in a webinar to discuss reimbursement rights of Medicare Advantage plans, and best practices for investigating and responding to reimbursement claims. For those who were unable to attend, or would like a refresher, we are pleased to provide below a summary of Mr. Bargender’s presentation along with some final thoughts and takeaways.

Medicare Advantage Plan Background

Part C Medicare Advantage plans (MA plans) are alternative delivery mechanisms for traditional Medicare benefits (Parts A and B) provided by private companies under contract with CMS. Medicare beneficiaries have the option of choosing one of these Medicare Advantage plans during annual or special enrollments periods. The three largest MA plan sponsors (representing almost half of the available plans) are UnitedHealthcare, Humana and Aetna. As of 2017, one-third of Medicare beneficiaries are enrolled in MA plans.

Medicare Advantage Plan Recovery Rights

Pursuant to CMS direction, MA plans must enforce the Medicare Secondary Payer Act (MSP) and will be audited by CMS for compliance with the Act. Consequently, these plans are obligated to coordinate benefits such that MA Plan coverage is denied when a primary payer is covering treatment and when the MA plan pays, but later learns of primary payer responsibility, seek reimbursement for payments made relating to the particular workers’ compensation, liability or no-fault claim.

MA plans right to reimbursement, including double damages, from NGHPs under the MSP Act has been acknowledged in at least two significant federal appellate court decisions:

• In re: Avandia, 685 F.3d 353 (3d Cir. 2012)
• Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229 (11th Cir. 2016)

Medicare Advantage Plan MSP Enforcement Challenges

Despite CMS’s direction to MA plans regarding enforcement of the MSP Act, including coordination of benefits, the data available to the MA plans to perform this task is inconsistent and error prone. Consequently, MA plans have taken one of three approaches to MSP enforcement:

Inactive: Minimal effort
Reactive: Relying upon member and medical provider reporting of primary plans
Proactive: Claim screening and investigation

As Mr. Bargender explained, Humana is taking the proactive approach. Nonetheless, the challenges faced by Humana in identifying coordination of benefits situations has proven difficult as a result of gaps in medical provider and Medicare beneficiary self-reporting and data provided by CMS which is “too little, too late, often wrong.” Additional challenges faced by MA plans are incomplete direction from CMS and non-cooperation of Medicare beneficiaries and plaintiff attorneys to MA plan reimbursement claims. As such, Humana utilizes a multi-faceted approach of member questionnaires, public records, such as accident reports and workers’ compensation claims, and non-public records, such as data relayed by CMS, to determine possible MSP coordination of benefits and reimbursement opportunities.

Best Practices for Non-Group Health Plans and MA Plan Reimbursement

Humana’s proactive approach then has the ultimate goal of reimbursement for charges related to the claimed injury. Mr. Bargender shared the following basic precautions to be taken by NGHPs:

• Train front-line staff on MSP basics – including MA & Part D
• Assume older & disabled claimants have some form of Medicare
• Be proactive when told claimants don’t have original Medicare
• Watch for other payer info in medical records
• Watch for notices from other payers
• No-fault and accepted work-comp claims
• Pay treating providers directly for outstanding medical bills
• Be suspicious of billing gaps (other payer?)

And when it comes to Liability and disputed or denied workers’ compensation claims:

Find out who paid for medicals

• Providers rarely wait for settlements
• CMS “no payment” letters aren’t the last word
• Request benefit ID card(s)
• Ask to see other payer “no payment” letters
• Medicare/Medicaid dual beneficiaries? …assume Part D paid Rx

Address MSP repayment before agreeing to settlement

• Determine amount before settlement is finalized
• Don’t assume plaintiff will reimburse MA plan or unpaid providers
• What does settlement indemnification language actually accomplish?

In terms of negotiating and resolving MA plan claims for reimbursement, Mr. Bargender offered as follows:

Most MA plans are open to working with primary payers

Focus on these:

• Rationale for denying beneficiary’s underlying claim, not MA/Part D rights
• Limits exhausted, treatment not allowed/capped, etc.
• What’s related (was it in the demand or release?)
• Errors in plan’s payment ledger
• Extenuating circumstances

Not on these:

• Reasonableness of amounts paid by MA
• Claim filing time limits vs. MSP statute of limitations
• Contract language” in the MA Evidence of Coverage document

Final Thoughts and Takeaways

In working with Mr. Bargender and the subrogation team at Humana, we have found them very helpful in promptly identifying specific reimbursement claim information where the claimant was enrolled in a Humana Medicare Advantage plan. Further, they are open to understanding the particular liability issues and bases for settlement, something not typically found with the Medicare conditional payment recovery contractors.

The primary takeaway from Mr. Bargender’s presentation is NGHPs must be proactive in identifying whether a Medicare eligible claimant is enrolled in a MA plan, and, if so, investigate whether the plan is seeking reimbursement for payments made related to the claim. As there exists no central database accessible to NGHPs in which to identify the MA plan a claimant is enrolled, the claims handler must be proactive in inquiring of the claimant whether they are enrolled in such a plan.

Tower MSA Partners will work with our clients to assist in identifying whether a claimant may be enrolled in a MA plan, identify the name of the plan and investigate whether such plan is seeking reimbursement stemming from the claim. We stand ready to assist you through general consultation on ensuring your MSP compliance program appropriately addresses MA plans or consultation on MA plan recovery* in a specific claim.

*While we did not delve into Part D Prescription Drug plans in this article, such plans arguably have similar reimbursement rights as Part C Medicare Advantage plans. NGHPs should also be aware of the potential for reimbursement claims from these plans.
Daniel Anders

The Centers for Medicare and Medicaid Services has chosen Performant Financial Corp. as its Commercial Repayment Center contractor to replace CGI Federal.

The announcement of a new CRC contractor comes after CMS said in an August report that the CRC had recovered $106 million in fiscal year 2016 out of $244 million in payments identified as owed to Medicare. The amount was a decrease from $150 million recovered in fiscal year 2015 despite the expanded pool of payers for CRC to pursue.

Daniel Anders, chief compliance officer for Tower MSA Partners, compared the non-group recovery amount to the billions of dollars spent each year on workers’ comp medical benefits.

“When you consider that the CRC’s authority to recover on behalf of Medicare encompasses all non-group health plans who have accepted responsibility for injury-related medicals, $6 million seems fairly small,” Anders said on Tuesday.

The full article may be found here.

A recent press release from the Performant Financial Corporation announced it has been awarded the Commercial Repayment Center (CRC) contract by the Centers for Medicare and Medicaid Services (CMS). Barring a bid protest, we expect a transition to the new CRC contractor over the next few months (CGI Federal’s contract, the outgoing CRC contractor, appears to run through 1/8/2018).

CRC Responsibilities

The Commercial Repayment Center is responsible for identifying and recovering primary payments mistakenly made by the Medicare program when another entity had primary payment responsibility (otherwise known as conditional payments). While CGI Federal has had the responsibility for recovering from group health plans for several years, it has been recovering from non-group health plans, such as a liability insurer, no-fault insurer, or workers’ compensation entity, only since 10/1/2015.

As those of you who have had any dealing with the CRC know, communication with the CRC following that start date was often frustrating as a result of long turnaround times to receive conditional payment information and inconsistent and contradictory responses from CRC representatives. While communication with the CRC has definitely improved over time, CMS has nonetheless chosen not to renew their contract with CGI Federal. CMS’s reasons are unstated, but as we noted in a recent article, CMS Releases Annual Report on CRC Conditional Payment Recovery, conditional payment amounts recovered by the CRC on behalf of Medicare declined from 2015 to 2016, despite the expansion of CRC’s recovery efforts to non-group health plans.

Besides the CRC contract, Performant currently acts as a Recovery Audit Contractor (RAC) for Medicare’s fee-for-service program (Parts A and B). As a RAC, Performant identifies and corrects improper payments made to medical providers as a result of insufficient documentation to support the payment, payments made which do not meet CMS guidelines and payments made for services that are incorrectly coded.

Similar to the RAC contract, the CRC contract is paid on a contingency basis. Consequently, the CRC contractor has an incentive to recover as much as possible on behalf of CMS. Per the Performant press release, “at full scale, Performant anticipates staffing the program with over 250 dedicated employees operating out of Performant’s offices around the country.”

CMS contractor transitions (see below bid protest) usually do not go as smoothly as advertised, thus we will wait and see how effectively this new contractor takes on the role as the CRC. We will advise you of any important developments during to and subsequent to the contractor transition.

WCRC Contract Under Protest

In a 9/11/2017 article, CMS to Transition to New MSA Review Contractor, we detailed the awarding of the new $60 million, five-year contract, for the Workers Compensation Review Center (WCRC) to Capitol Bridge, LLC. Two of the unsuccessful bidders, Arch Systems, and Ken Consulting, have filed formal protests to the awarding of the contract to Capitol Bridge. The protests are to be resolved by 12/21/2017. It appears then that this will delay the transition to the new WCRC. We will keep you apprised of any notable news on the WCRC transition.

The NAMSAP Annual Conference – MSP Policy Palooza 2017  – takes place September 27-29 in Baltimore.

Tower MSA Partners’ CEO Rita Wilson and Chief Compliance Officer Daniel Anders, MSCC will participate in two sessions at the National Alliance of Medicare Set Asides Professionals (NAMSAP) Annual Conference this month.

New rules, new contractors, new risks, and the ever-changing healthcare landscape keep the Medicare Secondary Payer (MSP) industry in constant flux. Where is it heading and how can MSP companies guide clients through changes? Wilson will join Gary Patureau, of the Louisiana Association of Self Insured Employers (LASIE), Optum’s Lavonya Chapman, and Sedgwick’s Michael Merlino to examine trends and prognosticate about the future. “MSP Predictions” will start at 10:45 a.m. on September 29.

“With a new Workers’ Compensation Review Contractor (WCRC), a new WCMSA re-review announcement and the potential for changes with Liability MSAs, payers need MSP guidance now more than ever,” Wilson said. “Presented from the payers’ perspective, this session will focus on the challenges of the current environment, future predictions and a ‘call to action’ for the MSP industry to drive future behaviors.”

Anders and Contact Claims Services’ Jeff Knipper will present the “Alignment of MSP Processes” on September 27 at 4:30 p.m. This session explores the connection among Section 111 reporting, conditional payments and MSAs.

“Traditionally the industry has viewed these as separate activities and kept them in silos,” Anders said. “But each impacts the other and you need a continuous, cohesive process to accurately manage every aspect.”

The NAMSAP Annual Conference – MSP Policy Palooza2017  – will be held at the Renaissance Baltimore Harborplace Hotel September 27-29, 2017.

For more information on the conference, see:

• NAMPSAP 2017 Annual Educational Conference

For more information on the Tower MSA Partners presenters, see:

• Tower MSA Partners Rita Wilson and Dan Anders to Speak At NAMSAP Annual Conference
• Rita M. Wilson
• Dan Anders

Tower MSA Partners will host a free webinar on Medicare Advantage and Part D Plan Recovery Rights on October 4 at 12:00 PM EDT. Tower MSA Partners is pleased to have Brian Bargender, of Humana, as the guest presenter for the Webinar. Humana is the second largest Medicare Advantage Plan and Part D plan in the country and has been the leading advocate for seeking reimbursement under the MSP Act from primary payers and Medicare beneficiaries for payments made through these plans.

Areas covered in the presentation are:

• Intro to Medicare Advantage and Part D Plans
• MSP guidance provided by CMS to MA and Part D Plans
• MA and Part D MSP enforcement rights
• Obstacles to enforcing MSP
• Tips for addressing MSP with MA and Part D plans

To register for the Tower MSA Premier Webinar, click here.

To read more about the Webinar, click here to read article posted on WorkersCompCentral about the Webinar.