Tower News

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

Related matter:

CMS: PAID Act Implementation Guidance & New ORM Termination Option

PAID Act Becomes Law

Proposed PAID Act Intends to ID Medicare Part C, Part D and Medicaid Enrollees for Insurers

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 info@towermsa.com or call us directly at 888.331.4941.

Related:

Tower CEO Rita Wilson Talks MSAs and Metrics in WorkCompWire’s Leaders Speak

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.

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 daniel.anders@towermsa.com or (888) 331-4941. We hope you can attend!

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:

CMS Issues Proposed Rule for Mandatory Insurer Reporting Penalties

CMP Comments Submitted

Payers do not need to report indemnity only settlements (no release of medicals) through Section 111 Mandatory Reporting because they are not considered a Total Payment Obligation to Client (TPOC). This reporting question that had long plagued/confused workers’ compensation payers.was recently clarified by CMS during the Q & A portion of the Section 111 NGHP Webinar.

Background

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.

Practical Implications

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.anders@towermsa.com or 888.331.4941.

Tower MSA Partners has completed its SOC 2 Type I audit. Performed by KirkpatrickPrice, this attestation provides evidence of Tower’s strong commitment to security and delivering high-quality services to its clients by demonstrating that it has the necessary internal controls and processes in place.

A SOC 2 Type I audit provides an independent, third-party validation that a service organization’s information security practices meet industry standards stipulated by the AICPA. During the audit, an organization’s non-financial reporting controls as they relate to security, availability, processing integrity, confidentiality, and privacy of a system are tested. The SOC 2 report delivered by KirkpatrickPrice verifies the suitability of the design of Tower’s controls to meet the standards for these criteria.

“Tower’s processes have been technology driven from its beginning with the privacy and security of client data at the forefront of internal policy and procedure development,” said Tower CEO Rita Wilson.  “We are pleased to receive this affirmation from an independent analysis.”

“The SOC 2 audit is based on the Trust Services Criteria. Tower MSA Partners has selected the security and confidentiality criteria for the basis of their audit,” said Kirkpatrick Price President Joseph Kirkpatrick. “Tower delivers trust-based services to its clients and by communicating the results of this audit, its clients can be assured of their reliance on this company’s controls.”

Related Posts

Tower MSA Partners Completes SOC 2 Type II Audit

Jesse Shade, Tower’s Vice President of Information Technology, will be a panelist on the “Cybersecurity Threats: What You Can’t See Can Hurt You” webinar. Presented by WorkersCompensation.com as part of its The Hot Seat series, the free webinar starts at noon EDT on August 6.

Shade, who is a member of the Forbes Technology Council, brings more than 35 years of IT experience to the panel. He oversees all aspects of Tower’s technologies, including data security. 

Joining Jesse Shade in the information-packed session is the George State Board of Workers’ Compensation’s Director of Information Technology Bobby Allen and WorkersCompensation.com’s Media Director Nancy Grover.

Among the topics Jesse Shade will cover are:

• Misconceptions about cybersecurity
• Should organizations outsource cybersecurity efforts?
• How can you guard against internet attack?

The webinar will be moderated by WorkersCompensation.com President and CEO Bob Wilson and Judge David Langham. There is no charge for the webinar.

WorkCompCentral.com covered Tower’s recent webinar “Avoiding the Medicare Mandatory Reporting Penalty” with Chief Compliance Officer Dan Anders and VP of Information Technology Jesse Shade.  CMS has yet to respond to comments or finalize the regulation proposed in February, but its proposal contained alarmingly high penalties for relatively minor infractions, like recording the wrong diagnostic code. 

The webinar highlighted various penalties for inaccurate or late reporting and demonstrated the new dashboard Tower built to help its clients find and fix reporting errors faster and easier.  The dashboard identifies claims with errors and the remedy to correct them. It also enables users to produce instant reports, such as a one showing claims with reported medical closure settlements or Total Payment Obligation to Claimants (TPOCs) where Ongoing Responsibility for Medicals (ORM) has not been terminated, a common reporting error.

For more information, please see Dan Anders’ Feb. 18 and April 27 blog posts on the proposed regulations or email Daniel.Anders@TowerMSA.com.

Nancy Grover of workerscompensation.com wrote an in-depth article on Tower MSA Partner’s “Avoiding Medicare Mandatory Reporting Penalties” webinar.  CMS is considering comments received to its proposed regulation that included penalties as high as $1,000 per day per claim. Final regs could publish any time. 

“There probably won’t be a lot of changes [in the final rule],” said Tower’s Chief Compliance Officer Dan Anders, who presented the webinar with Jesse Shade, VP of Information Technology.

Penalties could be imposed on organizations for not reporting a claim closure at all, exceeding error tolerance, or reporting contradictory information at different times. The article quoted Anders’ “contradictory information” example of a Medicare beneficiary with work-related injury on his right shoulder and a diagnoses code indicating the injury was on the right knee.

“CMS would have conflicting information. Even if the error is subsequently corrected, CMS could still impose a penalty of up to $365,000 [for a year],” he said.

To avoid penalties from even minor mistakes, Anders recommended that attendees note the omission of data, confirm the correct use of diagnosis codes, be sure to promptly report termination of ongoing responsibility for medicals or ORM.

“And ensure you have a reporting platform that is identifying potential errors and is working with you … to resolve errors and avoid penalties,” he said.

Tower is well positioned to serve as your reporting agent partner.  The company proactively developed its own Section 111 Mandatory Reporting dashboard, which Shade demonstrated on the webinar. He showed the many ways the platform helps users identify possible mistakes, address missing data points, confirm ICD9 and ICD10 codes, and run reports to direct their efforts.   Incorporating all the elements CMS examines, the dashboard simplifies and automates the process for users.

The dashboard is ready to roll as soon as CMS publishes the final regs.  As usual, Tower is ahead of the game — meeting clients’ needs before they know they have them.

Related

PREMIER WEBINAR: Avoiding the Medicare Mandatory Reporting Penalty