Posted on May 27, 2021 by Tower MSA Partners
Trying to bring more of your legacy claims to settlement?
This could be the most valuable webinar you’ll ever attend!
Do you have aging claims that continue to draw down on indemnity and medical reserves? Perhaps there is no ongoing medical, but the injured worker was unwilling to settle. Or maybe a claimant is willing to settle, but a prior MSA placed settlement out of reach.
These legacy claims can be settled with a program that aggressively addresses Medicare Set-Aside (MSA) cost drivers and mobilizes a settlement team that paves the way to claim closure–without increasing your adjuster’s workload.
You are invited to join Hany Abdelsayed, Tower’s expert in legacy claims settlement initiatives, for a fast-paced webinar on Thursday, June 24 at 2 p.m. Eastern. You’ll learn about:
- Recognizing legacy claims both obvious and hidden
- Identifying MSA cost drivers, which impede settlement
- Clinical interventions that contain MSA costs
- Settlement partners who clear the path to settlement/claim closure
A Q&A session will follow the presentation. Please click the link below and register today!
Posted on May 20, 2021 by Tower MSA Partners
Tower believes strongly that the true business value of a Medicare Set Aside (MSA) is in its ability to facilitate the settlement of a workers’ compensation claim. Dan Anders shared insight on this topic in this week’s WorkCompWire’s Leaders Speak column, Getting Real Value out of Your MSA.
Some WC payers see an MSA as a necessary evil when it comes to trying to settle a claim with an injured worker who is at or near Medicare age. They have an MSA company tally the future medical and pharmacy costs and either accept the allocated cost as is or freeze in sticker shock and put off any thought of settlement. They might even settle part of the claim and choose to keep medicals open and remain at the mercy of medical inflation.
But there’s another, better option: use the MSA as a settlement tool. Dan’s article lays out the facts and shows you how to use an “optimized MSA” and settlement partners to settle a workers’ comp claim.
What is an Optimized Medicare Set Aside?
The word optimize means “to make as effective, perfect, or useful as possible.” For Tower, a useful MSA helps settle a claim. An effective MSA achieves the perfect balance of care, compliance and cost.
Tower reviews the claimant’s medical records carefully for cost drivers – things like brand name drugs when generics are available or discontinued medications and inappropriate or open-ended treatment. Once these are identified, we recommend clinical interventions. With our clients’ approval, we implement these interventions. Our Physician Follow-up service, offered at no charge when preparing an MSA, clarifies medical treatment and drug regimens with the treating physician(s), escalates the case to Physician Peer Review when needed, and obtains physician statements that document current, appropriate treatment in language CMS can use to approve the MSA.
We make MSAs as useful as possible, and we know how to build a great team of settlement partners. Don’t settle for less.
If you have questions about settling with a CMS-approved MSA – or without one – or want to talk about any Medicare Secondary Payer compliance issue, contact Dan Anders at Daniel.email@example.com
Related Prior Posts:
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 penalties pretty seriously. But since these penalties have never been enforced, avoidance of penalties has not been a top concern.
It looks like Section 111 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 firstname.lastname@example.org 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 email@example.com.
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
Medicare Set Aside (MSA) companies and insurers will soon get help accessing accurate information necessary for Medicare reimbursements and settling workers compensation and liability claims.
Business Insurance’s Louise Esola wrote a nice article on a new law – the PAID Act – that clarifies expenses that workers’ comp insurers may have to reimburse. The article quotes Tower’s Chief Compliance Officer, Dan Anders, who explains how a new law would 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. Anders says:
“When preparing to settle a comp claim “everybody thinks we are hunky-dory, and they go and settle the case and a few months later (Medicare) Advantage comes in and sends in a reimbursement claim,” said Mr. Anders, who applauded the change. “This gives (insurers) better information that when the case is settled there won’t be any surprises. … They can investigate any claims for reimbursement and make sure that is resolved, so there are no issues months, years down the road.”
For the full article, see: New law clears air on Medicare reimbursements for comp insurers
Posted on October 12, 2020 by Tower MSA Partners
We passionately focus on metrics – it’s our driving force in making Tower Measurably Better.
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 firstname.lastname@example.org or call us directly at 888.331.4941.
Posted on September 23, 2020 by Tower MSA Partners
CMS webinar on CRC Appeals to focus on the procedures and best practices for redeterminations.
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 email@example.com 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 Section 111 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 Section 111 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.
For details, please see the news release: Tower MSA Partners Releases Medicare Mandatory Reporting Dashboard. And, for a quick refresher on CMS’s proposed penalties, see Tower’s Feb. 18 and April 27 posts:
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