Tag: CMS Re-Review

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.

CMS Proposes Expansion of WCMSA Re-Review Process – The Good, The Bad & The Ugly

March 16, 2014

On February 11, 2014, the Centers for Medicare and Medicaid (CMS) announced its proposed changes to the current Medicare Set-Aside Arrangement re-review process, seeking comments and feedback by March 31, 2014.

The current CMS process for WCMSA re-review requests is limited to situations where CMS is notified that the submitter omitted documentation from the original proposal, or when submitter believed there to be a mathematical error made by Medicare’s review contractor.  The re-review process in these situations will remain unchanged.     

Re-review requests may be submitted to the WCRC at any time for the following reasons:

  • A mathematical error was identified in the approved set-aside amount.
  • Original submission included case records for another beneficiary

 In its proposed expanded process, however, WCMSA re-reviews will be available for a broader array of categories and reasons.

 Re-review requests may be submitted to the WCRC ONLY when ALL of the following are met:

  • The original WCMSA was approved within the last 180 days,
  • The case has not settled,
  • No prior re-review request has been submitted for this WCMSA
  • The re- review requests a change to the approved amount of 10% or $10,000 (whichever is more).

Re-review requests may be submitted for ANY of the following when ALL qualifying criteria are met:  

  • Submitter disagrees with how the medical records were interpreted.
  • Medical records dated prior to the submission date were mistakenly omitted.
  • Items or services priced in the approved set-aside amount are no longer needed or there is a change in the beneficiary’s treatment plan.
  • A recommended drug should not be used because it may be harmful to the beneficiary.
  • Dispute of items priced for an unrelated body part.  
  • Dispute of the rated age used to calculate life expectancy

 In its explanation, CMS goes on to say that a re-review may be escalated by the WCRC to a CMS Regional Office “in certain situations”.  My assumption is that the decision would be at the discretion of the WCRC rather than by submitter request.  Examples identified included failure to adhere to court findings, CMS policy disputes, situations where the carrier maintains ‘Ongoing Responsibility for Medicals’ for treatment that has been included in approved WCMSA, etc. 

 The Good, the Bad and the Ugly

The ‘Good’….  On a positive note, I see any expansion to the re-review process as a good thing for the MSA industry.   I have seen countless times when I disagreed with the WCRC’s interpretation of the medical records, or I wanted to dispute prescription drugs or medical procedures that were being prescribed for unrelated body parts or were dangerous to the claimant. 

An opportunity to ‘challenge’ in these situations gives me new hope that the countless studies documenting the dangers of long term opioid use may now be introduced as rationale to exclude these drugs from the WCMSA.  This may also mark the beginning of the inclusion of state and national evidence based treatment guidelines to establish or dispute the appropriateness of treatment.

The ‘Bad’….  Am I being too optimistic?  The bad, as I see it, is that CMS provided us with nothing to explain how the information submitted in the re-review will be analyzed, nor does it list the criteria it would deem as acceptable evidence to justify a change.  Therefore, while positive on paper, it remains to be seen whether the expansion provides a real venue to evaluate appropriate care over life expectancy.

And the ‘Ugly’….  Unfortunately, I’ve seen multiple scenarios where re-reviews were submitted in follow up to what we believed to be complete omission of findings and recommendations in the medical records submitted to WCRC.  Upon re-review, the reviewer actually increased the allocation.  With the expanded re-review process, therefore, does the WCRC have total autonomy to modify/increase any portion of  the WCMSA, or will their response be limited to that portion of the WCMSA being challenged?     

Tower MSA Partners is currently preparing its response to CMS for submission on or before the March 31, 2014 deadline.   In doing so, one of the key points we will advocate to CMS is our strong belief that evidence based national and state medical and pharmacy guidelines should be included an any re-review process as a primary resource to establish appropriate treatment for long term pain management. As such, these should sit at the forefront of any assessment process. 

We solicit and welcome your feedback.