Posted on September 25, 2019 by Tower MSA Partners
The famed University of Alabama head coach, Paul “Bear” Bryant said, “when you make a mistake, there are only three things you should ever do about it: admit it, learn from it, and don’t repeat it.” These wise words are particularly applicable to termination of Ongoing Responsibility for Medicals (ORM) in the Medicare Section 111 Mandatory Insurer Reporting process. Failure to properly report ORM termination can yield unnecessary Medicare conditional payment demands, costing time and expense to resolve. When such an error is made, admit it to CMS, correct it, and learn from the experience so it is not repeated.
Background on ORM Reporting
Since October 5, 2015, the CRC has had responsibility for the recovery of conditional payments where the insurer or employer (including self-insured entities) is the identified debtor, known in CMS terms as the “applicable plan.” The CRC learns of opportunities to recover through the Section 111 Mandatory Insurer Reporting process. In other words, the applicable plan’s reporting is the catalyst for Medicare conditional payment recovery.
The mandatory reporting provisions of the Medicare Secondary Payer Act require the applicable plan to report to Medicare in three instances – the acceptance of ORM, the termination of ORM and issuance of a Total Payment Obligation to the Claimant (TPOC), settlement judgment, award or other payment.
ORM Termination Key to Cutting Off Liability to Medicare
Once ORM is accepted, CMS claims the right to recover against the applicable plan through the date of ORM termination. That means CRC’s recovery efforts may happen years after the ORM was first reported. Further, if the applicable plan fails to terminate ORM when appropriate, then the plan may receive CRC repayment demands for time periods in which it has no liability to pay for medical treatment.
Accordingly, terminating ORM when appropriate is vital to cutting off liability to Medicare. An applicable plan may terminate ORM through the Section 111 Reporting process under the following situations:
- Settlement with a release of medicals
- No-fault policy limit reached
- Complete denial of the claim
- Statute of limitations has run, or medical benefits have otherwise been exhausted pursuant to state law
- Judicial determination after a hearing on the merits finds no liability
- Signed statement from the injured individual’s treating physician that the injured party will require no further medical items or services associated with the claim related injuries.
Providing CMS with the ORM termination date gives a bookend to recovery by the CRC. If no termination date is provided, then CRC assumes the applicable plan remains liable for injury-related payments indefinitely.
Unfortunately, workers’ compensation claims systems do not always prompt the submitter when a settlement amount is entered to confirm whether ORM is also being terminated. As a result, the TPOC amount and date are reported to CMS, ORM remains at a “Y,” and the ORM termination date is left blank. This not treated as an error when CMS processes the submission as CMS allows for multiple TPOC amounts.
Consequently, unreported ORM termination dates can continue for years, and the RRE may only become aware of the oversight only when a conditional payment notice is received for the previously settled claim.
Tower’s client received a Medicare Conditional Payment Notice and then a demand from the CRC in the amount of $125,554. A review of the demand revealed many of the charges related to the injury which would typically present a challenge to requesting their removal from the demand. However, all the dates of service itemized in the demand were after the settlement date of 8/5/2014.
Upon further investigation it was learned that while a TPOC or settlement date of 8/5/2014 had been reported, ORM termination had not (Tower was not the Section 111 reporting agent for this client). Consequently, the CRC assumed that the primary plan was still accepting medical on the claim and asserted a demand for recovery of conditional payments.
Our client updated their Section 111 report with the correct termination date, and Tower was able to obtain CRC’s agreement to withdraw the demand.
In the end, our client was fortunately not held liable for repayment of $125,554 to Medicare. Nonetheless, the error of not reporting ORM termination concurrently with TPOC took several months to resolve.
Key Takeaway: Training, quality assurance and a reliable reporting agent are critical to avoiding ORM reporting errors.
- Train Adjusters on ORM Reporting: If an adjuster is responsible for inserting the data required for ORM reporting, then they require training as to when ORM acceptance and termination should be reported and how to determine the appropriate diagnosis codes to report. Significantly, anytime a TPOC (settlement) is reported, the adjuster should determine if medicals are closed as part of the settlement and whether the ORM termination date should also be reported.
- Effective Quality Assurance of ORM Reporting: Even with training, errors will occur. Additional resources placed into quality assurance of ORM reporting, such as double checking claims for proper ORM termination and appropriate diagnosis code choices avoids the expenditure of additional resources at a later date to correct errors in reporting and address unnecessary recovery demands from the CRC. If you are an employer or carrier relying upon a TPA to report, it is especially important to have a QA process in place to check the data entered by the TPA.
- Ensure Reporting Platform is Accurately Reporting: Section 111 Reporting is electronically based and requires a data exchange with Medicare. Errors can and will occur in this data exchange. Ensure you have a trusted and reliable reporting agent, like Tower, who will not only identify CMS submission errors, but also capture issues like a missing ORM termination date, and work with you to have them corrected prior to reporting to Medicare.
For questions stemming from this article or to inquire how Tower’s Section 111 Reporting platform can meet your compliance needs, please contact Dan Anders at (888) 331-4941 Daniel.email@example.com.
Posted on September 13, 2019 by Tower MSA Partners
Tower’s Executive Vice President of Clinical Operations, Patricia Smith, RN, BSN, MSCC, CDMS, CLCP, will be on the “Sources Right at Your Fingertips” panel of the National Alliance for Medicare Professionals (NAMSAP) 2019 Educational Conference. Scheduled for the morning of September 18, the presentation focuses on the resources used to determine pricing, coverage, and evidence-based medicine when preparing MSA allocations. Patricia will discuss the reference tools needed to analyze Medicare Coverage of medications, treatment, and durable medical equipment.
Then, on the afternoon of September 19, our Chief Compliance Officer, Dan Anders, will co-host the MSP Myths, Legends and Misconception Challenge. This will be an interactive Quiz Bowl to test the skills and knowledge of competing teams through serious and humorous questions.
Designed for professionals who are involved in Medicare Secondary Payer compliance and Medicare Set-Aside allocation and preparation as well as payers and attorneys who manage settlements, the 2019 conference will feature CMS contractors and present a wide spectrum of MSP and MSA topics, including reimagining the MSA Program, MSP policy activity, the current regulatory environment and recent case law.
The conference will be held at the recently reopened LIVE! Casino in Baltimore, Maryland, September 18-20. For registration options and other information, go to NAMSAP.org
Posted on August 26, 2019 by Tower MSA Partners
Here’s another great reason to go to NWCDC this year. Tower’s Chief Compliance Officer Dan Anders and Anne Alabach, Workers’ Compensation Department Manager for CPC Logistics, will discuss the art of partnering for optimal MSA outcomes. You may not realize how much your MSA vendor relationship affects MSA allocation amounts and the time it takes to settle and close a claim. Dan and Anne will give you valuable advice on ways to improve your relationship with your MSA partner and achieve optimal outcomes.
Plan to attend the session at NWCDC (Nov. 6-8) and visit our Booth #2517 to find out how Tower can help you improve your MSP compliance program. The conference will be held at Mandalay Bay in Las Vegas and more details can be found at the National Workers Compensation and Disability Conference.
Posted on August 8, 2019 by Tower MSA Partners
Attending WCI this year? Be sure to watch WCI-TV, which Tower is sponsoring for the 5th year. Representatives from American Airlines, Sedgwick, MedRisk, AMAXX, Safety National, and Tower will share the ways they measure the performance of their programs, including the metrics used and what they do with the results. For details, click here: Workers’ Compensation Experts Will Share Their “Metrics for Success” on Tower MSA Partners’ WCI-TV at WCI2019 #WCI2019.
Posted on July 29, 2019 by Tower MSA Partners
Through our quarterly webinars and in-person trainings, Tower offers our partners recent and relevant information combined with best practices in Medicare Secondary Payer compliance. However, once a year, a unique opportunity is presented by the National Alliance of Medicare Set-Aside Professionals (NAMSAP) at its educational conference.
This annual conference, which is sponsored by Tower, brings together the best industry minds, including representatives from CMS and its contractors for presentations and discussions on the latest in Medicare compliance. It is designed for professionals who are involved in all aspects or any aspect of MSP compliance, such as, adjusters and managers and claimant and defense attorneys.
A wide spectrum of MSP and MSA topics will be presented, including reimagining the MSA Program, MSP policy activity, the current regulatory environment and recent case law. Notable conference panelists include John Albert, a Senior Technical Advisor from CMS’s Division of MSP Operations, Jim Brady, Program Director of the Benefits Coordination and Recovery Center (BCRC) and Rose Arellano, Director of Outreach Recovery for the Commercial Repayment Center (CRC)
The conference will be held at the recently reopened LIVE! Casino in Baltimore, Maryland, September 18-20. For early registration options and other information, go to NAMSAP.org
We encourage you to attend and expand your knowledge of MSP compliance. If you have any questions about the conference, please contact Dan Anders at firstname.lastname@example.org or (888) 331-4941.
Posted on July 26, 2019 by Tower MSA Partners
Tower’s Dan Anders and American Airline’s Kris Sallee will present during two panels at the Workers’ Compensation Institute (WCI) Workers’ Compensation Educational Conference (WCI2019) this year.
Starting at 9 a.m. on Aug. 14, “Optimizing Settlement Outcomes by Measuring and Managing MSA Costs” stresses the importance of determining and using metrics to evaluate and improve your MSA program. The session will be moderated by Michael Stack, CEO of AMAXX, and Kris and Dan will also describe how clinical interventions produce MSAs that balance care, cost, and compliance. Then at 10:15, “Allaying the MSA Fear at Time of Settlement” Ametros CEO Marques Torbert and Structured Settlement Consultant Joe Bornstein join the panel to examine reasons employers and injured workers avoid settling claims.
For more information, see Tower MSA Partners’ Dan Anders to Discuss Metrics for MSAs and Claims Settlement Strategies at WCI 2019.
WCI2019 will be held August 11-14, 2019.
Posted on May 8, 2019 by Tower MSA Partners
Business Insurance’s Angela Childers turned to Tower’s Dan Anders for insight into how claims become catastrophic. Brand-name medications, opioids and the meds required to treat their side effects, and ineffective initial treatment are among the causes he cites. Payers can prevent cost escalation by having a “settlement mindset” from the beginning, he advises. Read more here. (registration or subscription will be required.)
Posted on May 3, 2019 by Tower MSA Partners
Dan Anders shared Tower’s experience on a possible trend to shift drug spend to ancillary services and alternative treatment (like acupuncture) and any effect on MSAs with WorkCompCentral’s Elaine Goodman. While another company said its average MSA amount was up 5.1% in 2018, Tower’s data shows a 13% decline in the average CMS-approved MSA. This is mainly due to reductions in prescription drugs, Anders said. And, although 66% of Tower’s MSAs were approved with no pharmacy allocation, Tower has not seen an increased allocation for non-pharmacy treatment. See more (subscription required) here.
Posted on April 26, 2019 by Tower MSA Partners
The concept of not submitting a Medicare Set-Aside (MSA) for approval from the Centers for Medicare and Medicaid Services has become an increasingly popular topic in workers’ compensation. This week’s WorkCompWire Leaders Speak features Tower Chief Compliance Officer Dan Anders’ insight on why it’s still OK to submit an MSA.
The article can be found here.
Posted on April 18, 2019 by Tower MSA Partners
How can you use metrics to evaluate your MSP compliance and MSA programs? And, what metrics apply? Tower CEO Rita Wilson shares key performance indicators, ways payers can use them in the settlement process and apply settlement strategies to on-going claims management in this week’s WorkCompWire Leaders Speak.
Here’s a brief excerpt:
“When issues are detected, the same clinical interventions (pharmacist-to-physician contact or physician peer review) used in the MSA process can be used to ensure the injured worker receives appropriate treatment and reduce costs to the claim. Payers can mitigate their eventual MSA exposure by managing the claim for settlement, and the PBM can help, but only if they know what will happen downstream.
Some payers tend to isolate MSP compliance, but it’s actually a continuation of claims management and critical to pre-settlement analysis. If payers have a high drug spend throughout the life of the claim, they are accepting a lifetime of spend at settlement. If they implement clinical interventions to reduce pharmacy usage early in the claim, they reduce its overall costs.”
Read the full article:Rita Wilson: Applying Settlement Strategies to Improve Ongoing Claims Management
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