CMS Archives - Page 2 of 5

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.

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

June 1, 2018

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.

New CMS MSA Review Contractor: Different Name, Same Policy and Procedures

March 7, 2018

While the review contractor is changing, the Workers’ Compensation Medicare Set-Aside (WCMSA) review policies and procedures remain the same. This was the message related to attendees of the Workers Compensation Review Contractor (WCRC) transition webinar held by CMS, yesterday, March 7, 2018. The purpose of the webinar was to introduce the WCMSA community to the new WCRC and provide information on the transition from Provider Resources, which ceases its work on March 16, 2018, to Capitol Bridge, which commences its work on March 19, 2018.

John Jenkins, CMS’s Health Insurance Specialist overseeing the WCRC contract, led off the presentation and then turned it over to Holly Haven, Capitol Bridge’s WCRC Project Director. Ms. Havens provided the following key information:

What is Not Changing

As our program matures, we will strive to improve both the quality of our work and the timeliness in which cases are completed through automation and our continual improvement focus.

The review and decision making process will remain the same.

WCMSA proposals will continue to be submitted through the portal or by mail to the same Oklahoma City address.

All established timeframes remain the same.

All inquiries will be handled by staff in our Pittsford, NY office, and customer service will be a priority.

Inquiries may still be communicated via telephone.

In summary, Capitol Bridge will continue to be guided by the guidelines laid out in the CMS WCMSA Reference Guide and maintain the 20-business day turnaround time for review of a WCMSA as required by CMS.

What is Changing

Processing of all cases will be handled out of their facility in Pittsford, NY.
New phone number for the WCRC is (833) 295-3773 with customer service hours from 9am to 5pm EST.
Email address for the WCRC is WCRC@capitolbridgellc.com
Fax number is (585) 425-5390

In the Q&A session following the formal presentation additional information was provided:

WCMSAs will be reviewed by RNs with the MSCC credential.
The WCRC staff includes attorneys, physicians and pharmacists.
WCMSA proposals which have not been reviewed by the outgoing contractor by March 16 will be transferred to the new contractor for review.
In response to a question as whether to expect an MSA backlog such that review times will lengthen, CMS noted that the outgoing contractor was typically completing its reviews in less than the required timeframe of 20 days.The implication then is the new contractor may be using the full 20 business days to complete its review.
A question was raised regarding Liability MSAs, but no answer was given as the webinar was not for the purpose of addressing policy questions.

While the CMS WCMSA policy remains the same, the interpretation and implementation of that policy will soon be in new hands. Tower MSA will be closing monitoring WCMSA reviews through Capitol Bridge to ascertain what, if any, differences can be identified in the allocation of care in the WCMSA compared to the prior contractor. Variances outside of established CMS guidelines will be challenged.

If you have any questions, please contact Dan Anders, Chief Compliance Officer, at 888.331.4941 or Daniel.anders@towermsa.com.

What Do Medicare Part D, Medicare Set-Asides and Parenting Have in Common?

March 2, 2018

parenting - father hugging two young children

For those who have raised children, or are in the process of doing so, one of our biggest challenges is to instill in our children some sort of positive decision-making paradigm in our children. You can call it religious values, moral absolutes, grounding, or just plain common sense, but as parents, we set boundaries (rules) from the earliest age, and try to be consistent in our enforcement. Our children may think we’re just mean, but this is a price we’re willing to pay if it helps establish an internal barometer to use when approached by people, thoughts and ideas that challenge them.

In raising my three children, one of the techniques I used was a simple, banded bracelet with the acronym, “WWJD” that is, What Would Jesus Do? This was a popular phrase in the Bible Belt where we lived. I asked that they look at the bracelet each time they were faced with an obstacle or asked to do something that didn’t quite feel right. One afternoon, my son was telling a story about something that happened at his elementary school that caused him to look at his bracelet. I was so pleased when he said he actually looked at it! He then responded, “Mom, I tried to decide what Jesus would do, but had a little bit of a tough time, so I switched it in my head to “WWMD”, and I knew exactly what Mom would do!” I couldn’t help laughing, but based on his response to the situation, my simple reinforcement worked. At the same time, this also reminded me that our actions speak much louder than our words….children will “do as we do” long before they will ”do as we say.”

How does this relate to Medicare Part D and Medicare Set Asides?

Each day, one of my first activities is to review my Google Alerts to look for news about NGHPs, Medicare Secondary Payer issues and opioids. This morning, the article that drew my attention was from MedPageToday.com entitled “CMS Proposes Opioid Prescribing Limits for Medicare Enrollees.” My first thought in reading the article was that this was great news.

“We are proposing important new actions to reduce seniors’ risk of being addicted to or overdoing it on opioids while still having access to important treatment options,” said Demetrios Kouzoukas, CMS deputy administrator and director of the Center for Medicare.

“We believe these actions will reduce the oversupply of opioids in our communities.”

Key components of the proposal include:

Hard formulary levels at pharmacies that would restrict the amount of opioids beneficiaries could receive
Establishment of a safety level of 90 morphine mg equivalent (MME)
Limiting the # of pills and days supply in an initial prescription for acute pain

According to Kouzoukas, “these are triggers … [that] can prompt conversations between physicians, patients, and plans about appropriate opioid use and prescribing.”

I then realized what CMS was doing. CMS was setting boundaries to help physicians, patients and plans make better decisions about opioid use…. the same type of boundaries I set for my children so they would make better decisions as adults. What a great idea! If physicians, patients and plans (both Medicare and workers’ compensation) can dialogue before Rxs are filled, better decisions about opioids are inevitable and the frequency of opioid addiction will diminish.

So what’s the problem?

Unfortunately, there remains a problem in the world of workers’ compensation and the WCMSA review process. While I applaud CMS’s effort, there remains a strong disconnect between CMS’s proactive stance on opioid limitations with Medicare Part D and its opioid-friendly review process for WCMSAs. At the same time, I must also admit to a similar disconnect between what happens with prescription opioids during the life of a workers’ compensation claim and what we are asking CMS to do when reviewing the MSA at settlement time. Are we asking CMS to “do as I say,” instead of providing the example of “do as I do?”

Can we ‘connect the dots’?

After reading the article, I realized that as an MSP compliance company that has integrated opioid triggers into its Pre-MSA Triage and review process since Day #1, Tower now has a new weapon in its arsenal to assist clients to identify pharmacy obstacles as early possible, and to address issues of inappropriate drug use. By advising clients to establish and enforce “CMS-like” boundaries at Rx fill time, we have the potential to reduce opioid use in workers’ compensation just as CMS seeks to accomplish with Medicare Part D. Through such efforts, we can reinforce dialogue between physicians, claimants and workers’ compensation plans before the Rx is filled, and hopefully facilitate better decisions about the first opioid Rx.

And as for the disconnect between Medicare Part D and the WCMSA review process, we cannot force CMS to change its WCMSA prescription drug review process. We can, however, leverage CMS’s expertise to support better outcomes with Medicare beneficiaries, MSAs and settlements by mirroring their Medicare Part D policies and processes within the workers’ compensation PBM model. In doing so, we provide CMS with a positive example of their own recommendations implemented successfully, and can hopefully encourage them to “do as we do.”

Conclusion

So how do we affect change in opioid prescribing habits in workers’ compensation? It’s as simple as the bracelet I gave my children. From Day #1 of a claim involving an active or soon to be active Medicare beneficiary, we continually ask the question, “What Would Medicare Do?” and we execute.

CMS Webinar to Introduce New MSA Review Contractor

March 1, 2018

Effective March 19, 2018, Capitol Bridge, LLC will be taking over responsibilities from Provider Resources as CMS’s Workers Compensation Review Contractor (WCRC). CMS has now announced a webinar set for Wednesday, March 7, 2018 at 1:00 PM ET to introduce the new MSA review contractor. See CMS Notice which includes a link to register for the webinar.

Capitol Bridge becomes the third company since 2003 to be awarded the WCRC contract. The contractor is charged with evaluating Workers’ Compensation Medicare Set-Aside (WCMSA) proposals submitted to CMS for review and approval. Using criteria set by CMS, it makes recommendations to the designated CMS Regional Office (RO) as to whether the proposed MSA amount adequately protects Medicare’s interests. If the WCRC disagrees with the proposal it will provide an alternate recommendation, either higher or lower, than the proposed amount. The CMS RO usually accepts the recommendation from the WCRC and issues the approval letter to the submitter of the MSA.

Besides the transition to the new contractor, what is unique about Capitol Bridge’s contract with CMS is the inclusion of a provision providing for the optional expansion of its MSA review responsibilities to liability and no-fault cases as early as July 1, 2018. We caution though that CMS has not announced that such an expansion will occur on July 1, 2018.

Tower MSA applauds CMS for inviting those impacted by the contractor change to this introductory webinar. On the heels of the January webinar introducing the new CRC contractor, we are pleased with more transparency by CMS in its process and policy changes. If you are unable to attend CMS’s webinar, Tower MSA will provide a summary of relevant information on our MSP Compliance Blog following the presentation.

CRC Contractor Change Brings New Team to Medicare Conditional Payment Recovery Efforts

January 21, 2018

On Thursday, January 18, 2018, the Centers for Medicare and Medicaid Services (CMS) held a webinar to introduce the new Commercial Repayment Center (CRC) contractor, Performant Recovery, and Performant’s management team. This transition to a new contractor is important to insurers and employers as the CRC is responsible for the recovery of Medicare conditional payments against these entities stemming from liability, workers’ compensation and no-fault claims where ongoing responsibility for medicals has been accepted.

Ted Doyle, the Performant MSP CRC Project Director, emphasized in his introductory remarks and throughout the presentation that their main goal is to make the transition seamless for all those who engage with the CRC. His message to stakeholders is CMS’s recovery processes and timeframes remain the same, it is only the entity handling those processes that is changing.

Besides Mr. Doyle, other webinar participants were John Albert, the Director of the CMS Division of Medicare Benefit Coordination and Laura Martinez, the MSP CRC NGHP Recovery Manager for Performant.

Key contractor transition information provided during the webinar was as follows:

The current CRC contractor, CGI Federal, will cease operations effective Friday, February 9, 2018.
Performant Recovery will commence CRC operations effective Monday, February 12, 2018.
Transition cutover, or what CMS calls “Dark Days,” will occur on February 8 and 9. During this period while CGI Federal will continue to answer telephone calls and the Medicare Secondary Payer Recovery Portal (MSPRP) will be available, the information will be limited to what was available at close of business on February 7. Also, uploading documents through the MSPRP will not be available.
Performant will go live as of 8am EST on February 12 at which point the MSPRP will once again be fully available as well as the call center. Correspondence received during the Dark Days or prior to the transition will be transferred to Performant for handling.

In regard to what will remain the same post-transition:

All current cases initiated by CGI will be transitioned to Performant.
Case information, copies of communication, correspondence and contact information, including letters of authority, will be fully accessible to Performant such that there should be no reason for stakeholders to resend correspondence or other information that was previously provided to CGI.
There will be no changes to CMS established recovery processes or timeframes applicable to MSP recovery.
The CRC Call Center will continue the same hours: 8am – 8pm EST
The CRC Call Center phone number will remain the same: (855) 798-2627
All Benefits Coordination and Recovery Center (BCRC) processes remain the same, including Section 111 Mandatory Insurer Reporting.

As for what is changing post-transition:

Effective 2/12/2018* the CRC has a new address:Medicare Commercial Repayment Center – NGHP ORM
P.O. Box 269003
Oklahoma City, OK 73216

*Any correspondence received prior to 2/12/2018 will be held and then processed starting on that date.
Effective 2/12/2018 the CRC fax number is (844) 315-7627.

As with any transition, some bumps are to be expected. We are hopeful these will be short-term and that the transition will not only be seamless, but that Performant improves the customer service aspect of the Medicare conditional payment recovery process. CMS and Performant engaging with Tower MSA and other stakeholders through this webinar is a good first step at building a collaborative relationship with those impacted by the CRC’s recovery efforts.

It was indicated a copy of the presentation slides will be made available on the downloads section of the CMS Coordination of Benefits and Recovery website next week.

If you have any questions regarding the CRC contractor transition, please contact Dan Anders at daniel.anders@towermsa.com or (888) 331-4941.

Daniel Anders, Esq., MSCC

Daniel M. Anders is the Chief Compliance Officer for Tower MSA Partners where he oversees the Medicare Secondary Payer (MSP) compliance program. Dan is an attorney licensed to practice in the State of Illinois and the United States District Court for the Northern District of Illinois.

CMS to Host Webinar on Transition to New CRC Contractor

January 9, 2018

On Thursday, January 18, 2018, at 1:00 PM ET, the Centers for Medicare and Medicaid Services (CMS) will host a webinar for the purpose of introducing the new Commercial Repayment Center (CRC) contractor to Non-Group Health Plans.

The CRC is responsible for recovery of Medicare conditional payments from liability insurers (including self-insured entities), no-fault insurers and workers compensation entities where such entities are the identified debtor by Medicare. It was announced last October that the new CRC contract had been awarded to Performant Financial Corporation (See Tower MSA article: New Commercial Repayment Center Contractor on the Horizon). The transition to the new contractor is to occur on February 8, 2018.

According to the January 5, 2018 CMS Notice, the webinar will consist of opening remarks and a presentation by CMS followed by a Q & A session. We encourage anyone who has regular contact with the CRC to register and attend the presentation (A link to register is located in the CMS Notice). If you are unable to attend, Tower MSA will provide a summary of relevant information on our MSP Compliance Blog following the presentation.

As CMS contractor changes are often fraught with a subsequent period of longer turnaround times and inconsistent communication with contractor representatives, we hope this transition proves an exception to past experiences. This introductory webinar appears to be a useful first step.

If you have any questions regarding the CRC contractor transition, please contact Dan Anders at daniel.anders@towermsa.com or (888) 331-4941.

Updated Section 111 User Guide Provides for Transition to MBIs, ORM Termination Defined

January 3, 2018

Pursuant to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, CMS is required to transition all Medicare beneficiaries from the Social Security Number based Health Insurance Claim Numbers (HICNs) to a new identification number called a Medicare Beneficiary Identifier (MBI). The primary purpose of this initiative is to reduce identify theft associated with use of Social Security Numbers in HICNs.

Accordingly, starting in April 2018 CMS will begin to mail new cards with the new Medicare numbers to Medicare beneficiaries. The goal is to issue all new cards by April 2019. For medical providers, there will be a transition period from 4/1/2018 through 12/31/2019 in which either the HICN or MBI will be accepted for processing of payments by Medicare.

Minimal Impact on Section 111 Reporting

Unlike medical providers which must exclusively use the MBI by 1/1/2020, as explained in the updated Section 111 NGHP User Guide, CMS has exempted its Medicare Secondary Payer Reporting processes from exclusive use of the MBI. Consequently, we can continue to report to CMS using a Social Security Number, a HICN or an MBI. In announcing this policy, CMS indicates it has renamed fields labeled “HICN” to “Medicare ID.”

While allowing for continued reporting of HICNs in its Section 111 reporting processes, CMS states that if an MBI has been issued to the claimant, it will return the MBI in the Section 111 response files. We expect then that while not requiring submission of MBIs, CMS nonetheless expects a natural transition to their use for MSP matters over time.

Medicare Conditional Payment Recovery Correspondence to Include Either HICN or MBI

As part of this update, CMS states that its recovery contractors, the Benefits Coordination and Recovery Center (BCRC) and the Commercial Repayment Center (CRC), will use either an HICN or MBI in its correspondence based upon the most recent information provided by the Responsible Reporting Entity (RRE) when creating or updating the MSP record. Again, we expect a natural transition from use of HICNs to MBIs in correspondence from the recovery contractors over the next few years.

The Tower MSP Automation Suite is fully capable of accepting SSNs, HICNs or MBIs for purposes of Section 111 Mandatory Insurer Reporting.

ORM Termination Defined

In addition to updating its User Guide to address the transition to MBIs, CMS also added language to its Section 111 “Policy Guidance” User Guide specifically defining under what circumstances Ongoing Responsibility for Medical (ORM) may be terminated. The revised Section 6.3.2 states as follows:

6.3.2 ORM Termination

When ORM ends, the RRE should report the date that ORM terminated and should NOT delete the record. Please note that a TPOC amount is not required to report an ORM termination date. An ORM termination date should not be submitted as long as the ORM is subject to reopening or otherwise subject to an additional request for payment. An ORM termination date should only be submitted if one of the following criteria has been met:

Where there is no practical likelihood of associated future medical treatment, an RREs may submit a termination date for ORM if it maintains a statement (hard copy or electronic) signed by the beneficiary’s treating physician that no additional medical items and/or services associated with the claimed injuries will be required;
Where the insurer’s responsibility for ORM has been terminated under applicable state law associated with the insurance contract;

Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits.

While now formalized, this ORM termination guidance had previously been provided by CMS, either in other sections of the User Guide or in guidance provided outside the guide, such as through CMS Townhall calls.

Notably, advocacy efforts have been made with CMS to request an expansion of the ORM termination criteria. Such expansion would, for example, provide for ORM termination if no medical has been paid on a claim over a certain number of years. The benefit of allowing for a greater number of claims to terminate ORM would be less of an administrative burden for employers and carriers and a reduction in denials of payment by Medicare for charges completely unrelated to reported claims.

Unfortunately, CMS has thus far been unresponsive to expanding its definition of ORM termination, choosing instead to work out improper denial of payments and unwarranted conditional payment recovery efforts on the back-end rather than addressing the quality of the data reported to CMS on the front-end.

The Updated Section 111 User Guide, Version 5.3, may be found here.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with any questions regarding the updated guide.

CMS Statement on Opioids and WCMSAs Provides Little Clarity as to Future Review Practices

December 27, 2017

In a recent post on its website, the Centers for Medicare and Medicaid Services (CMS) acknowledged the opioid crisis in this country, but provided little clarity as to how it intends to address this crisis in its review and approval of Workers’ Compensation Medicare Set-Asides (WCMSAs).

The 12/14/2017 statement provides as follows:

CMS understands the concerns regarding the opioid crisis occurring in the United States. We are committed to ensuring the determination of Workers’ Compensation Medicare Set Aside Arrangement (WCMSA) amounts are an adequate projection of claimant’s needs for future medical services and prescription drugs. CMS continually evaluates all policies and procedures related to WCMSA amounts. Any changes that Medicare pursues related to this issue will be reflected in our WCMSA amount review process.

More information on the WCMSA process can be found in the WCMSA Reference Guide.

We assume the above statement may be, in part, related to the California Workers Compensation Institute (CWCI) study finding nearly 70% of CMS approved MSAs require funding of opioids over an injured worker’s life expectancy (See our article, Opioids in the MSA . . . Challenges and Strategies, where this study is discussed). While we credit CMS’s Office of Financial Management (the CMS department which oversees the WCMSA review program and contractor) with recognizing the opioid crisis, what is left uncertain is what specific actions CMS is to take to address this problem in WCMSAs. Instead, CMS provides a vague statement indicating any changes related to the opioid issue will be reflected in its WCMSA review process and then cites its WCMSA Reference Guide.

CMS does not cite to a particular section of the guide, but we assume the following would be the most pertinent:

Drug Weaning/Tapering

Drug weaning commonly occurs with pain medications, such as opioids, especially when claimants’ work injuries improve. The WCRC takes all evidence of drug weaning into account, although in most circumstances the WCRC cannot assume that the weaning process will be successful. Usually, the latest weaned dosage is extrapolated for the life expectancy, but again, they assess all records when making these types of determinations. Where a treating physician believes tapering is possible and in the best interests of the claimant, CMS will consider all evidence in making a WCMSA determination, including medical evidence of current actual tapering.

Based upon the Tower MSA CMS Reconciliation Module, which reviews all MSA determinations for the purpose of identifying trends in CMS WCMSA allocation practices, CMS consistently disregards any active weaning or tapering process or scheduled reduction to future medication use and instead takes the latest dosage found in the medical records and/or prescription history and extrapolates it over the claimant’s life expectancy.

The question then is whether this December 2017 statement signals a departure by CMS from these past practices to a policy which will now give more weight to a weaning or tapering schedule from the treating physician which translates into limitations on the allocation of opioids in the WCMSA. We will take a wait and see approach in this regard.

It should be understood though that even were CMS to limit the allocation of opioids in the WCMSA, this in no way prevents the claimant from using the WCMSA funds for filling opioid prescriptions in excess of what is allocated. The reason being is CMS rules for administering a WCMSA allow for the funds in the account to be used for any Medicare-covered injury-related treatment or medication. As such, with a valid prescription, there is nothing to stop a claimant from converting funds allocated to a surgery to pay for medications, including opioids. It will remain then in the hands of the claimant’s medical provider to wean the claimant off opioids and other medications not intended for long-term use.

Practical Implications

As always, we will monitor CMS WCMSA determinations for signs of any changes to their allocating practices for prescription medications, especially in regard to opioids. However, we have to assume that until we see any changes, CMS will continue to follow its policy of taking the most recent medication dosage and frequency and pricing it out over the claimant’s life expectancy.

What this means then is opioid misuse must be addressed prior to submission of a WCMSA to CMS with any actual elimination of opioids documented in the medical records prior to submission of the MSA. Tower MSA is committed to working with our clients on reduction and elimination of opioids prior to CMS submission. Our Pre-MSA triage service is uniquely designed to identify such MSA cost-drivers and recommend intervention strategies, including escalating the matter to our Internal Pharm. D. for direct contact with the treating physician. Resulting reductions in opioid use limit MSA costs to the employer and provide for a healthier injured worker over his or her lifetime.

Please contact Dan Anders at Daniel.anders@towermsa.com or (888) 331-4941 with any questions regarding CMS practices in allocation of prescription medications in the WCMSA.

CMS Releases Statement Regarding Stakeholder Input in Liability MSA Review Process

October 27, 2017

CMS issued the following brief statement on their website this week:

The Centers for Medicare and Medicaid Services (CMS) continues to consider expanding its voluntary Medicare Set-Aside Arrangements (MSA) review process to include liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS will work closely with the stakeholder community to identify how best to implement this potential expansion of voluntary MSA reviews. Please continue to monitor this website for updates and announcements of town hall meetings in the near future.

Notably, very little information provided other than stating CMS will work with stakeholders before formalizing the expansion of the MSA review process to liability and no-fault. Based upon this statement, we can assume CMS will not spring the expansion on us, but give impacted parties an opportunity to comment before a final policy is put in place. Tower MSA will provide updates when further information is released by CMS or town hall meetings are scheduled.