What Gets Measured Gets Managed…. What’s Your Number?

July 23, 2018

man choosing form icond on a transparent technology touchscreen with a caption by Peter Drucker: "What gets measured, gets managed"

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 2017 performance in Tower’s total book of business as it relates to CMS approved MSAs and pharmacy costs,

56.9% of CMS approved MSAs with ongoing medical had $0 allocated for pharmacy;

72.7% 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,

Our pre-MSA intervention model yielded CMS approved MSA savings of 61.4% 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 2017,

Average turnaround time for Re-review determination and submission was <48 hours and CMS Re-review success rate was 78.8%.

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 new 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 Technology Driven MSP Compliance solutions, please email us at info@towermsa.com or call us directly at 888.331.4941.

Case Study: $951,189 in Savings Through MSA Optimization

July 19, 2018

CMS approval is not a legal requirement for an MSA. However, the potential financial repercussions for providing an inadequate MSA are such that many industry stakeholders find it wise to submit proposed MSAs to the agency.

Estimating the future medical costs takes enormous skill. For example, the final amount takes into account only the expenses related to the specific injury. Also, it needs to include things such as durable medical equipment that, while not needed presently, may be necessary in the future. Surgeries and other recommended medical treatments should also be included.

At the same time, the MSA should not include treatments or medications that are either not related to the injury or are not currently being used, or expected to be used by the injured worker. Unfortunately, when treatment recommendations are not clearly stated in the medical records, the concern that CMS may return a ‘counter higher’ response can lead many to overfund MSAs — especially, in the case of medications. – Michael Stack

 

Check out Tower MSA’s case study showing how  MSA optimization can save companies thousands of dollars.

Read it here.

New Medicare Numbers to Have Limited Impact on MSP Compliance Processes

July 12, 2018

sample image of a Medicare Health Insurance card

Since April 2018 the Centers for Medicare and Medicaid Services (CMS) has been issuing new Medicare identification numbers to some 60 million active Medicare beneficiaries. Pursuant to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, a Medicare Beneficiary Identifier (MBI) is replacing the Social Security Number (SSN) based Health Insurance Claim Number (HICN) on all Medicare cards issued to beneficiaries. An MBI is a unique, randomly generated alphanumeric identifier which will no longer include any portion of a person’s SSN. The primary reason the identifiers are being replaced is to limit identity theft associated with use of SSNs in Medicare IDs.

The process of issuing new Medicare cards with MBIs is to be completed by April 2019. Medicare beneficiaries and medical providers requesting payment by Medicare can continue to use either the HICN or MBI through December 31, 2019.   However, as of January 1, 2020, Medicare beneficiaries and medical providers must use the MBI to access Medicare-covered medical care and when requesting payment by Medicare for such care.

Limited Impact on MSP Compliance

While the statute requires CMS remove the SSN from Medicare IDs, it leaves an exemption allowing CMS to continue to utilize SSNs for purpose of Medicare Secondary Payer data exchanges and processes. Accordingly, for purposes of Section 111 Mandatory Insurer Reporting, Responsible Reporting Entities (RREs), may continue to use SSNs, HICNs or MBIs post January 1, 2020. However, when querying a claimant for Medicare beneficiary status or otherwise updating a report, if an MBI has been issued to the beneficiary, then the response file from CMS will be the MBI, not the HICN.

In regard to communication with the Benefits Coordination and Recovery Center (BCRC) and Commercial Repayment Center (CRC), SSNs, HICNs or MBIs may be utilized to ID the beneficiary. Correspondence from these entities, such as Conditional Payment Letters and Demands, will include either an HICN or MBI, depending upon the beneficiary ID which was most recently reported.

As for communication with the Workers Compensation Review Contractor pertaining to MSA submissions, SSNs, HICNs or MBIs may be utilized. Correspondence from the WCRC/CMS will include whatever beneficiary ID was submitted with the MSA proposal.

From a practical standpoint, what employers, carriers and other payers need to be aware of is they will increasingly be seeing these MBIs from claimants and responses from CMS and CMS contractors.

Tower MSA Partners will continue to monitor the transition from HICNs to MBIs and its impact on the MSP process. Any relevant updates will be provided with a breakdown of the implications to your practices and processes. If you have any questions please contact Dan Anders, Chief Compliance Officer, at 888.331.4941 or Daniel.anders@towermsa.com.

U.S. Attorney Recovers Against Plaintiff Attorney for Failure to Reimburse Medicare

July 2, 2018

close up of judge's gavel with the scales of justice in the background

A Philadelphia personal injury firm and its principal recently entered into a settlement agreement with the U.S. Attorney for the Eastern District of Pennsylvania to pay a lump sum of $28,000 for repayment of Medicare conditional payments. The June 18, 2018 press release from the U.S. Attorney’s Office explains that the law firm, Rosenbaum & Associates, and its principal, Jeffrey Rosenbaum, Esq., allegedly failed to reimburse this amount to Medicare stemming from nine settlements handled by the firm.

According to the release, Rosenbaum agreed to enter into a settlement with the federal government requiring not only reimbursement of the conditional payments but also to:

(1) designate a person at the firm responsible for paying Medicare secondary payer debts;

(2) train the designated employee to ensure that the firm pays these debts on a timely basis; and

(3) review any outstanding debts with the designated employee at least every six months to ensure compliance.

Rosenbaum also acknowledged as part of the agreement that “any failure to submit timely repayment of Medicare secondary payer debt may result in liability for the wrongful retention of a government overpayment under the False Claims Act.”

Practical Implications

This is another shot across the bow to plaintiffs’ attorneys warning them of their obligation under the Medicare Secondary Payer Act to ensure Medicare is appropriately reimbursed out of the settlement funds. Medicare regulations are clear in stating under 42 CFR 411.24 (g): “CMS has a right of action to recover its payments from any entity, including a beneficiary, provider, supplier, physician, attorney, State agency or private insurer that has received a primary payment.”

In regard to implications of this decision going forward, U.S. Attorney William M. McSwain said, “When an attorney fails to reimburse Medicare, the United States can recover from the attorney—even if the attorney already transmitted the proceeds to the client. Congress enacted these rules to ensure timely repayment from responsible parties, and we intend to hold attorneys accountable for failing to make good on their obligations.”

The provisions of the settlement agreement act as a roadmap for plaintiffs’ attorneys in ensuring Medicare conditional payments are properly resolved as part of settlement. For further consultation on Medicare conditional payment best practices in liability settlements, please contact Dan Anders, Chief Compliance Officer, at 888.331.4941 or Daniel.anders@towermsa.com.

 

 

Tower MSA Partners Names Jesse Shade Director of Information Technology.

June 29, 2018

Tower created an extremely sophisticated technology to drive best practices for MSP compliance and seamlessly link everything from Section 111 reporting through conditional payments, interventions, and MSA preparation and closure. The technology is complex on our end to make things easier for our customers, and it takes an expert to manage and constantly improve it. So, we are delighted to announce that Jesse Shade has joined Tower to do just that. For more information, click here Tower MSA Partners Names Jesse Shade Director of Information Technology.

Tower CEO and NAMSAP President Rita Wilson and other NAMSAP officers warned employers about MSAs allocating for opioids when speaking at the National Council of Self-Insurers (NCSI) last week.

June 22, 2018

Tower CEO and NAMSAP President Rita Wilson and other NAMSAP officers warned employers about MSAs allocating for opioids when speaking at the National Council of Self-Insurers (NCSI) last week.

Tower MSA Partners’ Rita Wilson and Other NAMSAP Directors Discussed Opioids and MSAs at the National Council of Self-Insurers Conference

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

June 1, 2018

US Capitol dome

On 5/18/2018, the Provide Accurate Information Directly Act (or the proposed PAID Act) was introduced in Congress for the purpose of allowing settling parties an easy method to identify if a claimant is enrolled in a Part C or D plan or Medicaid.  The bill, H.R. 5881, sponsored by U.S. Rep. Gus Bilirakis R-Fla and U.S. Rep. Ron Kind, D-Wisc, requires the Centers for Medicare and Medicaid Services (CMS) to share information on not only whether a claimant is a Medicare beneficiary, but also whether the claimant is enrolled in a Part C Medicare Advantage (MA) Plan, Part D Prescription Drug Plan or Medicaid.  It also requires CMS to provide the identity of the MA or Part D Plan or state Medicaid program in which the claimant is or was enrolled.

The catalyst for this legislation comes from stepped up efforts by these various plans and programs, especially by MA Plans, to seek reimbursement from settling parties. MA Plans have largely prevailed against insurance carriers in seeking reimbursement under the Medicare Secondary Payer Act which has led to a heightened awareness of the potential for such claims and the need to identify claimants enrolled in such plans and programs prior to settlement.

While liability and no-fault carriers and workers’ compensation plans are now on notice of the potential for such reimbursement claims, there presently exists no universal method to identify a claimant’s enrollment status, short of asking the claimant.  Accordingly, the bill provides a solution by requiring CMS to share such enrollment information.

A review of the proposed PAID act shows the enrollment information would be shared through the Section 111 Mandatory Insurer Reporting query process.  In short, along with identification of whether a claimant is a Medicare beneficiary, the query response would also provide whether the claimant is or has been enrolled in a MA or Part D Plan or a state Medicaid program for the past three years and the name of the plan or program.  The insurance carrier or self-insured entity would then be able to readily contact the Part C or D plan or Medicaid program to resolve any claim for reimbursement.

The bill was referred to the Committee on Ways and Means and the Committee on Energy and Commerce for further action.  Tower MSA Partners will provide updates on the legislation when warranted.

2018 Annual Meeting and Vendor Showcase

banner announcing 2018 NCSI Florida conference

Please join us June 10 – 13! We are pleased to be a Silver Sponsor and Exhibitor at the NCSI annual Meeting and Vendor Showcase.

Tower’s CEO, Rita Wilson, will be presenting on Tuesday, June 12 @ 9:30am as part of the NAMSAP Panel.