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Premier Webinar: WC Settlements in Light of CMS Policy on Non-Submit MSAs

Posted on January 25, 2022 by Tower MSA Partners

The Centers for Medicare and Medicaid Services (CMS) recent policy statement which considers non-submit/evidence-based MSAs “as a potential attempt to shift financial burden” to Medicare left many questions in its wake (See CMS: Non-Submit MSAs Potentially Shift Costs to Medicare).  It has triggered many payers, along with injured workers and their attorneys, to reconsider the choice to avoid the CMS MSA review and approval process.

On Thursday, February 3 at 2:00 PM ET, Tower’s Chief Operations Officer Kristine Dudley and Chief Compliance Officer Dan Anders will address the many questions which arise out of this announcement and walk attendees through how a move from a non-submit to submit MSA program can still yield cost-effective settlements with the added protection of CMS approval.

Here’s just some of what you will learn:

  • Background on CMS policy on submit vs. non-submit MSAs and what it means for the future of MSAs
  • Potential defenses to CMS claim that a non-submit MSA was deficient
  • A how-to guide to transition from non-submit to submit MSA program which still settles WC cases
  • Tools available to contain MSA costs whether the MSA is submitted or not

While the webinar focus is on those that have primarily pursued a non-submit MSA course, portions on MSA cost containment and ensuring the availability of MSA funds over a lifetime are important to submitters and non-submitters alike.

A Q&A session will follow the presentation, and you can send your questions to Daniel.Anders@TowerMSA.com now. Please click the link below and register today!

Register here

Tower’s Dan Anders Reviews MSP Policies from Last Year and Predicts 2022 Actions

Posted on January 20, 2022 by Tower MSA Partners

WorkersCompensation.com’s Nancy Grover captured the thoughts of Tower’s Chief Compliance Officer Dan Anders on a variety of Medicare Secondary Payer and Medicare Set-Aside issues from 2021 and 2022 in a recent article.  MSAs cost less than you think, opioid allocations are down, and the PAID Act makes obtaining Medicare Advantage Plan data easier. Plus, the Centers for Medicare and Medicaid Services flat-out said that MSAs that are not approved by CMS could be “a potential attempt to shift financial burden” to Medicare.

The article, “MSA Policy Updates, Changes Likely in Store for 2022, Expert Predicts,” can be read here. Remember it’s just a one-time process of subscribing to this free section of Workerscompensation.com.

CMS Releases Updated Section 111 NGHP User Guide

Posted on December 28, 2021 by Daniel Anders

The Centers for Medicare and Medicaid Services (CMS) has released Version 6.6 of its Section 111 NGHP User Guide.  Below is a summary of the notable updates and practical implications.

Funding Delayed Beyond TPOC Start Date Field

Last month we discussed an 11/03/2021 Alert from CMS on the use of Field 82 Funding Delayed Beyond TPOC Start Date.  Field 82, per the Section 111 User Guide, is to be used in specific circumstances where the amount the claimant Medicare beneficiary is to be paid is not known at the time the settlement occurs.  Per CMS, this happens most often in mass tort settlements.

As we previously related, the CMS Alert is confusing when it refers to the date settlement funds are “dispersed.”  CMS seems to assume that the date inserted into Field 82 is not only the date that the settlement amount is determined but is the same date the funds are dispersed. However, these dates may be weeks or months apart.  Our recommendation was to place the date settlement funds are dispersed in Field 82.

In its update to the User Guide, CMS now acknowledges this as the correct use of Field 82.  Specifically, CMS states (Chapter III: Policy Guidance):

6.5.1.2 Timeliness of Reporting

NGHP TPOC settlements, judgments, awards, or other payments are reportable once the following criteria are met:

  • The alleged injured/harmed individual to or on whose behalf payment will be made has been
    identified.
  • The TPOC amount (the amount of the settlement, judgement, award, or other payment) for
    that individual has been determined.
  • The RRE knows when the TPOC will be funded or disbursed to the individual or their
    representative(s)

RREs should retain documentation establishing when these criteria were or will be met. RREs

should not report the TPOC until the RRE establishes when the TPOC will be funded or

disbursed. In some situations, funding or disbursement of the TPOC may not occur until well

after the TPOC Date. RREs may submit the date the TPOC will be funded or disbursed in the

corresponding Funding Delayed Beyond TPOC Start Date field when they report the TPOC Date

and TPOC Amount, but must do so if the TPOC Date and date of the funding of the TPOC are

30 days or more apart.

Timeliness of MMSEA Section 111 reporting for a particular Medicare beneficiary will be based

upon the latter of the TPOC Date and the Funding Delayed Beyond TPOC Start Date.

Example:

There is a settlement involving an allegedly defective drug where a large settlement is to be

disbursed among many claimants.

The settlement provides a process for subsequently determining who will be paid and how much.

Consequently, there will be payment to or on behalf of a particular individual, but the specific amount of the settlement, judgment, award, or other payment to or on behalf of that individual is not known as of the TPOC Date. RREs are to submit the date of the settlement in the TPOC Date field and the amount of the settlement in the TPOC Amount field.

In this example, the determination of the TPOC Amount, as well as the funding or disbursement of the TPOC, will be delayed after the TPOC Date. Once the TPOC Amount and the date when the TPOC will be funded or disbursed are determined, the RRE should submit the record with the appropriate date in the corresponding Funding Delayed Beyond TPOC Start Date field.

Practical Implications

What CMS is getting at here is they want to know when the claimant receives the settlement funds so they can correctly time their recovery efforts.  For Responsible Reporting Entities (RREs) this means if payment will be delayed more than 30 days post the TPOC date, then they must hold off on Section 111 reporting until the date the settlement funds will be disbursed has been identified.

We note that while CMS expects the above rule to apply to mass tort settlements, there are certainly cases, both liability and workers’ compensation, where funding may be delayed more than 30 days beyond the TPOC date.   Thus, we believe the effect of this update on the “Timeliness of Reporting” rule will likely be much wider.

In terms of making this simpler for those entering the TPOC information, if the disbursement of settlement funds commonly occurs more than 30 days post-TPOC date, it may be easiest to always enter a date in the corresponding Funding Delayed Beyond TPOC Start Date field along with the TPOC Date and TPOC Amount, whether less than or more than 30 days from the TPOC date.

Updates to No-Fault Policy Limit

Also last month we discussed another CMS Alert reminding RREs where, depending upon state law or the terms of a given policy, the no-fault policy limit may vary.  The Alert reminded RREs to update to the new policy limit as quickly as possible, including the use of an “off-cycle” report (A report made in addition to the required quarterly reporting).  In our analysis of this Alert, we expressed concern as to whether such “off-cycle” reporting is mandatory or recommended.  In other words, if mandatory and not done, that it would be considered non-compliance and potentially subject the RRE to penalties.

The updated User Guide CMS states as follows (Chapter III: Policy Guidance, Section 6.5.1.3):

Note: In some states, depending on various factors associated with the incident being reported, no-fault policy limits may vary. The reported Policy Limit should reflect the amount the RRE has accepted responsibility for at the time the record is submitted or updated. Just as importantly, if the Section 111 record needs to be corrected to reflect a new Policy Limit, the RRE should update the record as soon as possible.

Practical Implications

While CMS states the RRE should update the record as soon as possible, there is no reference to “off-cycle” reporting.  We assume that while “off-cycle” reporting is preferred, that proper compliance will be determined based upon the quarterly report which includes the updated no-fault policy limit.

$750 Threshold Maintained for Section 111 Reporting and Medicare Conditional Payment Recovery

In a December 15, 2021, Alert CMS announced the 2022 recovery threshold for liability, no-fault and workers’ compensation settlements will remain at $750. Accordingly, Total Payment Obligations to the Claimant, TPOCs, in the amount of $750 or less are not required to be reported to CMS through the Section 111 Mandatory Reporting process, nor will CMS attempt to recover conditional payments for TPOCs of this amount (The threshold does not apply to liability settlements for alleged ingestion, implantation or exposure cases).

Practical Implications

As CMS is keeping the $750 threshold for mandatory reporting and conditional payment recovery there are no changes to the reporting processes or determinations as to when conditional payments should be investigated or resolved.

If you have any questions regarding these updates, please contact Dan Anders at daniel.anders@towermsa.com or 888.331.4941.

 

 

 

 

 

A Holiday Wish from Tower MSA Partners

Posted on December 22, 2021 by Tower MSA Partners

Earlier this year Tower MSA Partners celebrated its 10th anniversary. As 2021 comes to a close we again thank you, our client partners, for your support and loyalty, some for all of those 10 years and some for only the past few months.  Your trust in us to provide MSP compliance services and settlement solutions is never taken for granted . . . nor do we rest on our laurels.

The Tower team looks forward to launching into a new year with new initiatives and enhancements to provide you the best in customer service, systems and controls which keep client data secure from cyber threats and a commitment as your partner to help settle claims that provide the best in care, cost and compliance.

Our wish to you is a safe, happy and healthy holiday season filled with warmth and laughter.  Merry Christmas and best wishes in the new year.

 

How Did Workers’ Comp Execs Fare During COVID-19?

Posted on December 10, 2021 by Tower MSA Partners

How has the Covid-19 affected workers’ comp organizations? What changed professionally for risk managers and claims professionals during the pandemic? Did temporary policies become permanent? Tune to WCI-TV to find out.

Tower MSA Partners has been the exclusive sponsor of WCI-TV since its inception.

“Instead of commercials for our Medicare Secondary Payer compliance services, we’ve explored topics like opioid management, how success is measured, and ways to overcome barriers to claim closures,” said CEO Rita Wilson.

Naturally, an ongoing, international Covid-19 pandemic rated attention. “We wanted to hear how organizations maintained a sense of unity while working from home and how lockdowns changed sales, marketing, and purchasing practices,” explained Chief Compliance Officer Dan Anders.

Among Tower’s TV guests will be Susan Shemanski, Vice President of Corporate Risk Management of the Adecco Group, Joe Berardo, CEO of Carisk Partners, Porter Leslie, CEO of Ametros, and Mark Meyer, Claim Attorney with the Montana State Fund.

WCI-TV airs throughout the convention center and shuttles, in hotel guest rooms and on WCI’s website YouTube channel. These interviews will also be available on Tower’s LinkedIn homepage.

Tower is pleased to be part of the 75th Annual WCI Conference; see for more https://www.wci360.com/conference/ information.

Related:

Tower MSA Partners Arranges for CMS Officials to Headline WCI’s MSP Sessions

Forbes Features Tower CTO‘s Article, “How to Help the Masses Make Sense of Cybersecurity”

Posted on December 8, 2021 by Tower MSA Partners

Tower’s Chief Technology Officer Jesse Shade has published an article on the Forbes Technology Council channels, reminding fellow IT pros that most tech users don’t understand cybersecurity. And that when IT folks explain why doing certain things are important, users are more likely to do them.  Here’s his explanation of Multi Factor Authentication or MFA:

MFA stands for multifactor authentication. It is a security solution that requires more than one method of proving (authenticating) your identity. You have already used MFA if you have ever logged into an online account and were asked to provide information so you could:

 Receive a verification code via text or email.

  • Provide an answer to a security question.
  • Receive a verification code on a phone or computer authenticator application.
  • Use biometrics (fingerprint or facial recognition) on your computer or phone.

The rationale behind MFA is that if a bad actor gains access to your username and password, they aren’t likely to also have your mobile phone or computer where you will receive the second factor. It is even less likely they will have your fingerprint, retinal scan or the answers to your security questions. There are multiple factors to authenticate that you are who you say you are, hence, MFA.

How to Help the Masses Make Sense of Cybersecurity is a must-read piece on the role of IT pros in arming non-IT tech users to serve as the front-line cybersecurity force they must be.

Feel free to reach out to Jesse at jesse.shade@towermsa.com.

Related:  Building a Better Tower – Cybersecurity

Tower MSA Partners Arranges for CMS Officials to Headline WCI’s MSP Sessions

Posted on November 30, 2021 by Tower MSA Partners

When the WCI Conference invited Tower MSA Partners to produce the first day of its Medicare Secondary Payer (MSP) compliance track, Tower asked representatives from the Centers for Medicare and Medicaid Services (CMS) to kick-off a trio of MSP panels.

“It’s the 20th anniversary of CMS launching its Medicare Set-Aside (MSA) review program,” said Tower’s Chief Compliance Officer Dan Anders.  “We thought this would be a great opportunity for attendees to listen and ask questions of the key policymakers on all matters related to MSP enforcement.”

The section will start with a CMS Townhall covering such matters as the implantation of the PAID Act and how not to run afoul of CMS when submitting an MSA at 1 p.m. on Tuesday, December 14.  Anders will moderate the Townhall. Panelists appearing via video will be Deputy Director of MSP Program Operations Jackie Cipa, Director MSP Program Operations Steve Forry, and John Jenkins, Jr., Health Insurance Specialist, Division of MSP Program Operations, CMS.

Following at 2 p.m. is “Don’t Forget Medicare Conditional Payments!” moderated by Tower’s Chief Operating Officer Kristine Dudley and featuring Rasa Fumagalli, Director of MSP Compliance with Synergy Settlement Solutions and Heather Schwartz Sanderson of the Sanderson Firm.

“Conditional payment matters frequently take a backseat to Medicare Set-Asides,” Dudley said. “These experts will show you how to discharge Medicare conditional payment and Medicare Advantage plan reimbursement demands with confidence for both injured worker and payer.”

Anders returns as a panelist with Ametros General Counsel Shawn Deane and Mark Meyer, Claim Attorney for Montana State Fund, for the 3:15 p.m. session, “It’s Still Ok to Submit an MSA.” Sanderson will moderate the discussion designed to show how to balance care, cost and compliance to secure a CMS-approved MSA.

The 75th Annual WCI Conference will be held December 12-15 at the Orlando World Center Marriott.  Please see https://www.wci360.com/conference/.

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

Posted on October 12, 2021 by Tower MSA Partners

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

Tower MSA Partners 10-Year Anniversary and 10 Distinguishing Achievements

Posted on September 21, 2021 by Rita Wilson

We’re celebrating the Tower MSA Partners 10-year anniversary this year! To commemorate this landmark year for our business, we’ve compiled 10 distinguishing achievements over the decade that we’re proud of and that we think differentiate us from others in our field.

  1. Our single focus. We don’t try to be all things to all people, we focus on doing one thing extremely well. Everything we do is geared toward smooth settlements with 100% compliance with Medicare, cost-effective Medicare Set-Asides (MSAs) and partnering with clients on outcomes. Focusing our business model on Medicare Secondary (MSP) compliance and MSAs enabled Tower to develop technology specifically for this industry, hone our expertise, and become the industry’s “go-to” experts in these areas.
  2. We are “Measurably Better.” Our tag line “Measurably Better” is not just a clever use of words, it’s the backbone of all that we do. We run our business on metrics, tracking and measuring everything that matters in MSP compliance and MSAs.  Metrics drive Tower’s internal efficiency improvements and technology enhancements.  It’s how we help our clients improve their MSP compliance and MSA programs and how we prove we—and our clients’ programs–are measurably better.
  3. Our commitment to continuous improvement. We’ve aggregated 5 years of CMS response data to identify CMS performance metrics that matter to our clients and we track these monthly. And we continue to monitor every response CMS has to every one of our MSA submissions. When we think CMS is wrong, we challenge by proactively pushing the envelope to get the best possible results for our clients. Otherwise, we use the response data to reverse engineer internal processes to improve our MSA work product.
  4. Everything we do is technology driven. We built our own technology from the beginning specifically to address this industry and our clients’ needs. Our technology is based on the best practices of MSP compliance and MSA preparation. There’s no patchwork of disparate systems or data in silos that needs to be extracted, just a seamless, integrated system that drives all compliance and MSA processes.  Tower’s Section 111 Management Dashboard gives clients full visibility into their claims from a global level all the way down into the details of an individual claim. Technology Drives Better Medicare Secondary Payer Compliance.
  5. Our commitment to cybersecurity. With a clear understanding of the importance of our systems, software, and data to Tower’s business functions and a keen awareness of the reality of cyberthreats in today’s digital environment, Tower has taken major steps to develop its enterprise-wide security infrastructure to guard against, detect and mitigate cyberattacks. This includes partnering with a data security firm that monitors data traffic 24/7, responds to threats in real time, provides direction to keep client data secure, and gives Tower unlimited access to incident response resources if attacks occur. monitoring data traffic 24/7, responding to threats in real time and   Building a Better Tower – Cybersecurity.
  6. We’ve earned external third-party validation.  Tower MSA Partners completed its SOC 2 Type II audit, providing external third-party validation that a service organization’s information security practices meet industry standards stipulated by the AICPA. Tower MSA Partners Completes SOC 2 Type II Audit.
  7. We are independent and women owned. We are wholly owned by our founders, CEO, Rita Wilson and COO, Kristine Dudley, Tower is a certified Women’s Business Enterprise (WBENC). Celebrating Tower’s History as a Women-Owned Business.
  8. Our stellar team. You can meet our outstanding leadership team, the top experts in the business. The passion and dedication of our certified MSA specialists, nurses, Quality Assurance team, and compliance staff are incredible. Their efforts enable Tower to manage by our metrics and drive results. Many have been with us since the beginning and became managers as they gained knowledge and skills. We are a cohesive team at all levels. But for our real secret sauce, learn more about how Tower Nurses Make a Difference.
  9. We get results. Our systematic, aggressive approach to identifying and reducing unnecessary cost-drivers on MSAs saves clients hundreds of thousands of dollars on MSAs. Our certified specialists know what to look for and our technology, metrics, and processes give them all the tools they need to find every cent of savings. Because we record CMS response to every MSA, we can confidently produce MSAs that balance care, cost, and compliance.  Check out our case histories, request others or ask for a free second opinion on an MSA.
  10. Our clients love us. Hers’s an excerpt from one: “Second to None”….When I hear this idiom, I immediately think of Tower MSA Partners… While there are many MSA vendors, only one company, Tower MSA Partners, is “Second to None.” Tower serves their partners by guiding and directing from start to finish. They have advanced technology and certified specialists to ensure no stone is unturned. Regardless of the complexity or how fast you need help, Tower leads and delivers results that are always accurate and timely, serving you like family. Bryan Conner, Manager, Workers’ Compensation, American Airlines. See our Testimonial page to read more from Bryan and our other clients.

We are honored to serve clients like American Airlines, Acuity Insurance, Aramark, BETA Healthcare Group, CPC Logistics, Montana State Fund, Tyson Foods, and others, some who prefer not to have their names published.  From the beginning, Tower sought partnership relationships with clients; we put “partners” in our name.

On our 10th Anniversary, I want to thank our client partners who have trusted us with their MSP and MSA needs, our employees who are just stellar, and our executive leadership team who are the best of the best.  We look forward to continuing to serve our existing clients, help new ones achieve their goals, and continue our close partnerships.

 

Tower Non-Submit MSA: A Reasonable Alternative

Posted on September 1, 2021 by Tower MSA Partners

To submit or not submit a Medicare Set-Aside for approval from the Centers for Medicare and Medicaid Services (CMS) has been a hot-button issue for several years.    While some follow a global non-submit strategy others opt to follow CMS’s guidance, where possible, considering a non-submit MSA only in specific situations.   Whether a Non-Submit MSA is utilized for settlement depends on several factors and risk tolerances, and Tower MSA Partners stands ready to analyze your claim and help you decide.

A Non-Submit MSA, sometimes called an Evidence-Based MSA, may be a reasonable alternative when the settlement does not meet CMS’s Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) review thresholds. It may seem obvious to use a Non-Submit MSA when the MSA will not be submitted to CMS, but as the methodology in drafting the Non-Submit MSA varies from CMS policy (as detailed below) some prefer to stick to CMS policy for drafting the MSA, even when not submitted.

Besides utilizing a Non-Submit MSA when CMS MSA review thresholds are not met, as the review process is voluntary, settling parties may choose a Non-Submit MSA even when the review thresholds are met.  This carries with it inherent risks in that CMS takes the position that if the funds set-aside prove insufficient “Medicare will refuse to pay for services related to the WC injury (and otherwise reimbursable by Medicare) until such expenses have exhausted the entire dollar amount of the entire WC settlement.”

A Non-Submit MSA report may have a lower allocation amount than a CMS-approved MSA because of the following features:

  • Full Use of Evidence-Based Medicine – Use of evidence-based medicine, i.e., Official Disability Guidelines (ODG) or state treatment guidelines to determine reasonable care to allocate in MSA.
    • CMS inconsistently uses evidence-based medicine in its MSA review process. Using ODG and state treatment guidelines may result, for example, in a lower frequency of diagnostic testing or physical therapy visits compared to a CMS-approved MSA.
  • Examining Physician Opinions Considered – Both treating and examining physician recommendations are considered in drafting the Non-Submit MSA.
    • CMS gives little consideration to examining physician opinions in its approval process.  Depending on the case, the examining physician may be in a better position to provide appropriate recommendations for current and future medical care because of their expertise and the timing of their opinion.  For example, a recent IME opinion on the necessity of surgery may be followed as opposed to a treating physician recommendation from a year ago.
  • State Statutes and Regulations Followed – Fully follow state statutory, regulatory, and other legal bases for including or excluding care from the MSA.
    • While CMS approval requires an “Alternative Treatment Plan” when medical care is denied through a statutory utilization review (UR) process, a Non-Submit MSA will exclude care solely based on the UR determination.  For example, a prescription medication will not be allocated in the MSA when a UR determination supports denial.
  • Claimant Statements and Agreements Considered – Consideration of claimant statements and settling party agreements concerning future medical care.
    • CMS will not usually exclude the cost of care from an MSA for a procedure or device, such as a spinal cord stimulator, based on a claimant’s statement that they will not pursue that care. Yet that statement or an agreement among the parties that certain medical care is disputed and not included in the settlement, is sufficient for a Non-Submit MSA. For example, evidence of the claimant repeatedly refusing surgery will usually result in its exclusion from the MSA.
  • Professional Administration Recommended: Except for minor MSA allocations, Tower strongly recommends having a professional administrator manage the Non-Submit MSA funds. If CMS ever questions the use of these funds, proper administration will confirm they were spent properly, enabling a seamless transition to Medicare for payment if the funds run out. And, Tower proudly partners with Ametros for professional administration of all MSAs: Non-Submit MSAs and those that are CMS-approved.

Depending on the facts of the case, a Non-Submit MSA can have a significantly lower allocation than a CMS-approved MSA and still reasonably consider Medicare’s interests.  Nonetheless, using a Non-Submit MSA poses risks to the settling parties that should be fully considered and accepted prior to settlement.

Tower offers free consultations on Non-Submit MSAs. If you have any questions about these or other areas of Medicare Secondary Payer compliance, please contact Dan Anders, Chief Compliance Officer, at daniel.anders@towermsa.com or 888.331.4941.

For Media Inquires, Contact:

Helen King Patterson
813.690.4787
helen@kingknight.com

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