2nd Opinion MSA Review Yields $98,120 in Savings

An MSA was prepared by another MSP provider for $221,384. The client asked Tower for a 2nd Opinion MSA Review, which is offered at no charge. Tower identified treatment for body parts that were not covered and eliminated costs for prescriptions that were unrelated to the injury along with inappropriate medical treatment, including an unnecessary surgery. In addition, Tower obtained a rated age that reduced medical and pharmaceutical costs over the life expectancy. The new MSA was submitted to and approved by CMS for $123,263.68, saving the client $98,120.

$774,583 Total Savings from Pre-MSA Triage

Case submitted to Tower for Pre-MSA Triage to assess Medicare exposure. In 2010, worker was doing electrical line work when he was struck by lightning. Injuries included electric shock with pain, insomnia, depression and seizure activity. Treatment included prescription drugs as follows: Hydrocodone/ APAP (7.5 / 325 mg at 4 / day), Baclofen (muscle relaxant), Topamax (anti-seizure), Cymbalta (anti­depressant), Keppra (anti-convulsant), Naproxen (pain), Clonazepam (anti-anxiety). Cost drivers included Keppra and Topamax, both with generic available, but being prescribed, filled and paid by carrier as brand. Total MSA Exposure -$1,416,513.

MSA Optimization Yields $175,000 Reduction

Tower was engaged to prepare an MSA for a 54-year-old partial quadriplegic. The lack of current medical records, the erratic behavior of the patient, the quality of the provider’s treatment coding, and unknown treatment outside of the WC Plan were challenges to preparing an accurate MSA. The preliminary MSA amount was $424,528.

Free Physician Follow-Up Captures $231,487 in Savings

An initial MSA for a Medicare beneficiary with low back, groin, hip, and knee pain came in at $285,151. Medical records showed discontinued prescriptions for Amrix, Celebrex, and Amitriptyline.  Tower’s Physician Follow-Up service–which comes at no charge as part of an MSA CMS submission–clarified the drug regimen.  Then, Tower drafted and obtained a signed attestation letter from the treating physician that confirmed the only medications being prescribed for the work injury were Oxycodone/APAP 525mg BID and three injections per year.  Tower documented this statement and submitted a $53,664 MSA to CMS, which approved it within nine days for a savings of $231,487.

$1 million in Savings from PPR

Chronic pain associated with cervical injury. Patient had multiple surgeries with current treatment consisting of Oxycontin 60 mg (4/day), Oxymorphone 10 mg (4/day) coupled with antidepressant, NSAID, muscle relaxant and insomnia treatment. At time of MSA preparation, total morphine equivalent dosage = 480 MED/ Day and the total MSA projection = $1,234,551.

Clinical Oversight Confirms $210,143 Reduction

Claimant sustained industrial injury to head and neck in 2009. Diagnoses at the time of MSA preparation included concussion, headache, anxiety and depression. Intervention triggers identified by Tower’s clinical team included combined use of opioids and benzodiazepines, multiple prescribers, multiple antidepressants, and off label use of lamotrigine. Total Morphine Equivalent Dosage (MED) was 160 mg/ day and patient was experiencing opioid induced side effects. Total MSA cost projection = $269,015.

43% Reduction in Open Claims

A large, national employer inherited legacy claims through a merger/ acquisition transaction increasing total open claims to 5,000 with total reserves at greater than 695,000,000. Seeking to reduce the number of open claims and claim cost, lower the number litigated claims, reduce pharmacy/ drug costs globally and as a percentage of total medical costs and optimize the value of the MSAs and obtain CMS approval, the employer initiated a ‘claims closure project’. Tower was contacted to partner with employer, carrier, physician peer review and settlement partners to manage MSA and post-MSA intervention strategies for all claims involving Class I and 11 Medicare beneficiaries.

Conditional Payments Reduced to $0

Conditional Payment Notice submitted to Tower for potential dispute. Charges identified by the CRC included multiple hospital stays, ER visits and surgeries, as well as treatment by unauthorized treating physicians as per the state’s worker’s compensation statute. State of jurisdiction was California. Accepted body part was lumbar spine. Total conditional payment exposure was $71,349.

Amended Review Drops MSA by $101,312

CMS approved an MSA for $147,483 in May of 2015, but by the time the parties were ready to settle the MSA no longer reflected the current course of medical care. While CMS’s Amended Review process allows the submission of a new MSA, it has to be submitted within one to four years of the original. With less than two months to meet the deadline, Tower reviewed the medical records and took action. The injured worker was no longer using a supplemental oxygen delivery system and he was taking Crestor, which was now available as a generic. Tower followed up with the treating physician who confirmed the oxygen system was discontinued and agreed to switch to the generic. By documenting these treatment changes appropriately once the injured worker was using the generic, Tower was able to revise the MSA down to $46,171, submit it to CMS days before the deadline, obtain CMS approval, and provide the client a savings of $101,312.

Re-Review Results in $0 MSA

Tower submitted a $0 MSA based on a treating physician’s statement that a work-related, right shoulder rotator cuff sprain had completely resolved with no need for future medical care. CMS responded with a $17,729 counter-higher that included annual orthopedic visits, multiple primary care physician visits per year, diagnostic testing, physical therapy, and Norco. Tower’s Re-Review included medical records from the claimant’s primary care physician documenting that Norco was prescribed for an unrelated low back condition. The Re-review re-asserted the treating physician’s confirmation that the work-related injury was resolved and said that the claimant had returned to work at full duty and there had been minimal reports of pain. CMS removed all future treatment and medication costs from the MSA and approved the $0 allocation.