compliance Archives

$231K in Savings from Free Physician Follow-Up

March 4, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 6 $231K in Savings from Free Physicians Follow-Up.

In Tower MSA Partners’ previous post, Trimming the Fat, $175K in Savings Through MSA Optimization, we explained how MSA optimization removed $175,000 in unnecessary projected costs. In this case, a payer asked Tower to validate the treatment plan for a complex claim through physician follow-up. By engaging the treating provider, confirming current medical needs, and obtaining a physician attestation, Tower reduced the projected Medicare Set Aside (MSA) lifetime cost by $231,487 and secured CMS acceptance without development.

Identifying the Problem

The claimant’s original MSA had been created more than two years earlier. Since that time:

Multiple prescriptions were listed without up-to-date clinical context
Treatment frequency and diagnoses were not validated
The projected costs reflected outdated assumptions

Without direct clinical confirmation, the allocation risked inflating projected future costs and faced potential CMS scrutiny. The payer needed a defensible allocation grounded in current medical reality.

The Physician Follow-Up Solution

Tower’s clinical team initiated physician follow-up, adhering to jurisdictional rules for secure outreach. The process included:

Reviewing the full set of updated medical records
Confirming active medications, dosages, and indications
Discussing current therapy frequency with the treating physician
Validating the absence or tapering of unnecessary prescriptions

The physician confirmed that the only active prescription was Oxycodone/APAP 5/325 mg and that certain therapies were no longer needed. Armed with this clinical confirmation and a signed attestation, Tower updated the allocation.

The result was a $231,487 reduction in projected MSA costs — fully documented, fully supported, and defensible.

Collaboration and Communication

Tower MSA Partners didn’t just update numbers in a spreadsheet. Every correction was explained clearly to the claims professional and documented. The physician’s signed attestation — verifying current care and confirming that outdated items were no longer clinically necessary — was included in the CMS submission.

Because the revised MSA included accurate current clinical information and a valid attestation, CMS approved the allocation quickly and without development requests.

Why Physician Follow-Up Makes the Difference

Treatment plans evolve, medications change, and assumptions in an early allocation can become outdated. Without direct validation from the treating physician:

Medications may be mischaracterized
Frequencies may be overstated
Lifetime projections may overestimate future care

Physician follow-up ensures the MSA reflects actual current need, which:

Controls costs
Enhances compliance
Strengthens defensibility in CMS review

This case shows that physician engagement isn’t a luxury — it’s a strategic lever for both accuracy and savings.

Lessons Learned

Physician engagement validates clinical need and clarifies current care.
Signed attestations give CMS confidence in the accuracy of the allocation.
Outdated medications and therapies can be confidently removed when confirmed to be clinically unnecessary.
Defensible projections protect payers from excess costs and speed CMS review.

Results That Reflect Expertise

With targeted physician follow-up and attestation:

The payer realized $231,487 in reduced lifetime MSA costs
The updated allocation aligned with clinical reality
CMS approved the allocation without development requests

Tower MSA Partners delivered transparent documentation, accurate projections, and a cost-conscious, defensible settlement outcome.

FAQs

What is physician follow-up?

Physician follow-up is direct communication by Tower with the treating provider to confirm current medical treatment, active medications, and therapy needs. It ensures MSAs reflect accurate, individualized clinical information.

How does physician follow-up create savings?

By validating care with the treating physician, unnecessary treatments and medications can be removed or corrected in the lifetime projection, reducing projected future costs.

Is physician follow-up accepted by CMS?

Yes. When physician follow-up includes clear clinical documentation and, if required, a signed statement, CMS will accept updated MSAs and often approves them without development requests.

When should physician follow-up be used?

Physician follow-up can be used anytime there is open-ended medical care, outdated treatment recommendations or inconsistent or contradictory medication history.

Key Takeaways from CMS Webinar on Civil Money Penalties

January 21, 2026

On January 15, 2026, CMS held a webinar on Civil Money Penalties (CMPs) for Non-Group Health Plan (NGHP) Section 111 Reporting. This was CMS’s final update before the first audits and penalty notices in the first quarter of 2026. Given that penalties can be substantial and impact an organization’s compliance record, understanding these requirements and deadlines is essential for all Responsible Reporting Entities (RREs).

CMS provides a full explanation of its CMP policy on its website here.

Quick Reference: Critical Dates

February 2026: First CMS audits begin
March 2026: First penalty notices expected
July 2026: Workers’ compensation penalty assessments begin

Audits

CMS will conduct its first audits in February 2026. The audit will randomly select 250 records from all accepted Section 111 records and non-Section 111 records obtained through CMS’s coordination of benefits and data collection methods. The 250 records will proportionally represent both NGHP and Group Health Plan (GHP) records from the prior quarter.

For the February 2026 audit, CMS will evaluate records accepted between October 11, 2025, and December 31, 2025. CMS will look forOngoing Responsibility for Meedicals (ORM) assumptions or Total Payment Obligation to the Claimant (TPOC)(TPOC) reported more than 365 days after the reportable event. This applies to ORM assumptions and TPOC dates of October 11, 2024, or later.

What Triggers Penalties

Penalties are assessed when RREs fail to report required information within mandated timeframes. Specifically, CMS looks for:

ORM assumptions reported more than 365 days after the reportable event
TPOCs reported more than 365 days after the reportable event

Special Consideration for Workers’ Compensation

As a result of the implementation of WCMSA reporting in April 2025, CMS announced that it will not assess penalties for late-reported workers’ compensation TPOCs until July 2026, with a lookback period to July 2025 instead of October 11, 2024. This grace period allows RREs to adjust to the new WCMSA reporting requirements.

Safe Harbor Protection

CMS provides a safe harbor when an RRE cannot report a TPOC because the claimant failed to provide information necessary to identify them as a Medicare beneficiary (such as their Social Security number).

Requirements to qualify for safe harbor:

Make two attempts to obtain the information from both the beneficiary and their attorney by mail or email
Make one additional attempt to either the beneficiary or their attorney by phone, mail, or email
Document all attempts with dates, methods, and responses
If either the claimant or their attorney provides a written refusal to cooperate, no further attempts are needed

Important notes:

Federal law does not prohibit the RRE from contacting the claimant directly, even when the claimant is represented by an attorney
Contact must be made with both the attorney and the claimant until one of them either provides the information or provides a written refusal

All documentation of these attempts must be retained and provided to CMS if a penalty arises.

Acceptable documentation includes copies of emails, certified mail receipts, phone logs with dates and summaries of conversations, and written refusals.

Penalty Notice Process

Informal Notice

CMS expects the first penalty notices to be sent in March 2026. These informal notices will be mailed to the RRE’s Authorized Representative, with a copy to the Account Manager. Importantly, the reporting agent (such as Tower or other third-party administrators) will not be copied on the notice.

Action required:

Given the importance of receiving these notices, RREs should immediately verify that their Profile Report contains up-to-date contact information for both the Authorized Representative and Account Manager.

Upon receipt of an informal notice, the RRE has 30 days to provide a response, including a reasonable explanation as to why either the TPOC report or the ORM assumption report was untimely.

Possible defenses include:

The claimant refused to provide their Social Security number (safe harbor applies)
Delayed acceptance of a claim due to litigation or investigation
Administrative errors with documented corrective measures
Technical issues with CMS submission systems

If CMS accepts the explanation, there will be no further action.

WC Reporting Penalties

Formal Notice

If CMS does not accept the explanation or there is no response to their informal notice, a formal notice, called a Notice of Proposed Determination to Impose a Civil Money Penalty, will be mailed to the Authorized Representative and copied to the Account Manager for the RRE.

Appeals Process

The appeals process provides multiple levels of review:

Level 1 – Administrative Law Judge (ALJ): The RRE has 60 days from receipt of the Proposed Determination to appeal to an ALJ.

Level 2 – Departmental Appeals Board: If the ALJ’s decision is unfavorable, the RRE has 30 days to file an appeal with the Departmental Appeals Board Appellate Division.

Level 3 – Federal Court: If the Departmental Appeals Board appeal results in an unfavorable decision, the RRE has 60 days to petition for judicial review in federal court.

Payment

Once the appeals process has concluded, or if no appeal is filed, a Notice of Final Determination will be sent to the RRE. The RRE has 60 days from receipt to make payment electronically through pay.gov.

Best Practices and Final Thoughts

The timeliness and accuracy of Section 111 reporting will mitigate and, ideally, eliminate any possibility of a penalty. To protect your organization:

Proactive measures:

Implement robust processes to capture Medicare beneficiary information at first contact
Establish clear procedures for the three-attempt safe harbor requirement with documentation templates
Maintain detailed records of all attempts to obtain beneficiary information
Review and update your CMS Profile Report contact information immediately
Develop internal timelines that build in buffer time before the 365-day reporting deadline

If you receive a penalty notice:

Respond immediately within the 30-day window
Coordinate with your Section 111 reporting agent, if applicable, to identify all possible defenses
Gather all documentation supporting your explanation

Please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com with any questions.

A $98K Mistake Avoided, The Value of Second Opinion MSA Reviews

January 12, 2026

Image of Tower MSA Partners Why Case Studies Matter series, Blog 4 A $98K Mistake Avoided with a Second Opinion MSA Review

In Tower MSA Partners’ previous post, we explained how Physician Peer Review generated more than one million dollars in savings while strengthening CMS compliance. This month, we shift focus to the importance of accuracy. Tower MSA Partners was asked to review a Medicare Set Aside allocation prepared by another company, and the findings revealed a significant error that would have cost the payer ninety eight thousand dollars. This case illustrates why a second opinion is a valuable safeguard in every MSA strategy.

Identifying the Problem

The claim involved ongoing treatment, therapy, and pharmacy exposure. The original MSA prepared by another vendor appeared complete, and the projected costs seemed typical for this type of injury. Once Tower MSA Partners reviewed the file, the clinical team found inconsistencies that required deeper investigation. Several treatment projections did not align with the documented medical record. The file also listed duplicate items and outdated medications that had already been removed from the claimant’s regimen. The largest issue involved a discontinued high-cost prescription that remained in the allocation. This error inflated the MSA by nearly one hundred thousand dollars and created unnecessary CMS risk. If submitted as written, the payer would have funded care that no longer existed and faced questions about clinical justification.

The Second Opinion Solution

Tower MSA Partners completed a complete second opinion MSA review. Analysts verified each treatment recommendation and cross-referenced records with the most current documentation. Pharmacy history was compared to recent physician notes to ensure accuracy. The discontinued medication was the key discrepancy. The treating physician had replaced it with a lower cost, safer alternative, and the original reviewer failed to revise the allocation. Tower updated the MSA to reflect the correct medication plan and documented the clinical reasoning in clear, concise terms. With the correction in place, the projected cost of the MSA decreased by ninety-eight thousand dollars while maintaining complete alignment with CMS guidance.

Collaboration and Communication

Tower MSA Partners emphasizes transparency in every step of the review. The clinical team explained each correction and helped the claims professional understand why the original allocation was inaccurate. This clarity supported confident decision making and prepared the file for CMS submission. Tower also communicated updates with the defense attorney and treating provider, so all parties understood the medical basis for the revisions. When submitted to CMS, the revised MSA was approved without development requests. Accurate documentation and clinical alignment created a predictable approval process.

Why Oversight Makes the Difference

Accuracy is essential in Medicare Set Aside management. Even a small oversight can inflate lifetime medical projections and expose the payer to avoidable costs. A second opinion MSA review provides an essential layer of validation that confirms medical necessity, eliminates outdated information, and protects the overall integrity of the claim. This case demonstrates that clinical oversight and cost savings work together. Correcting the allocation not only protected the payer from unnecessary spending but also ensured that the file met CMS expectations with confidence.

Lessons Learned

A second opinion review prevents costly mistakes and confirms accuracy before submission.
Outdated information leads to inflated costs, especially in pharmacy heavy claims.
Strong clinical documentation makes CMS approval predictable and efficient.
Precision drives savings. The ninety-eight-thousand-dollar reduction resulted from careful review and experienced analysis.

Results That Reflect Expertise

By requesting a second opinion, the payer avoided a ninety-eight thousand-dollar over allocation and gained a compliant, defensible Medicare Set Aside. The corrected review reflected actual medical necessity and prevented unnecessary long-term funding. This case highlights Tower MSA Partners’ continued commitment to accuracy, clinical alignment, and cost containment. A second opinion review is more than a quality check. It is an essential safeguard for payers, claimants, and settlements.

FAQs

What is a second opinion MSA review?
A second opinion review evaluates an MSA prepared by another company to confirm accuracy, clinical validity, and compliance with CMS guidelines.

How do second opinions create savings?
They uncover outdated treatments, discontinued prescriptions, and projection errors that inflate total costs.

When should a second opinion be considered?
Any claim with complex medical history, high pharmacy exposure, or uncertainty about the accuracy of an existing MSA benefits from a second opinion.

What is a second opinion MSA review?

A second opinion review evaluates an MSA prepared by another company to confirm accuracy, clinical validity, and compliance with CMS guidelines.

How do second opinions create savings?

They uncover outdated treatments, discontinued prescriptions, and projection errors that inflate total costs.

When should a second opinion be considered?

Any claim with complex medical history, high pharmacy exposure, or uncertainty about the accuracy of an existing MSA benefits from a second opinion.

$1 Million Saved with Physician Peer Review

December 4, 2025

In Tower MSA Partners’ previous post, we explored “How Pre-MSA Triage Prevented $774k In Unnecessary Costs” by diagnosing issues before submission. This month, we move from prevention to precision. Through a comprehensive Physician Peer Review, Tower MSA Partners helped a client reduce projected MSA costs by more than $1 million, reinforcing how clinical oversight transforms both financial and compliance outcomes.

Identifying the Problem

The claim involved a long-term pain management case where the claimant had been prescribed multiple overlapping therapies and high-cost medications for years. On paper, everything appeared compliant, but Tower’s experienced analysts recognized red flags. The medications had not been re-evaluated for clinical necessity, and several treatments were duplicative or no longer consistent with current medical standards.

Left unchecked, the proposed MSA would have locked the payer into unnecessary costs for the claimant’s lifetime medical care. Beyond the financial impact, the payer also faced potential CMS scrutiny for including treatments without supporting clinical documentation. This is where Tower MSA Partners’ layered review process stepped in.

The Physician Peer Review Solution

Tower’s team initiated an independent Physician Peer Review, assigning the case to a licensed physician with expertise in pain management. The reviewer conducted a full analysis of the medical history, treatment progress, and prescription patterns. This deep clinical evaluation uncovered that several medications could be tapered or replaced with safer and lower-cost alternatives.

For example, the claimant was taking a combination of opioid medications that exceeded current best practice guidelines. The reviewing physician documented a detailed rationale for modification, providing evidence-based recommendations that were not only medically sound but also compliant with CMS expectations.

Once incorporated into the revised MSA, these adjustments reduced projected costs by more than $1 million while maintaining patient safety and treatment continuity.

Collaboration and Communication

One of Tower MSA Partners’ key strengths lies in its ability to bridge communication between medical reviewers, claims professionals, and legal teams. Rather than simply returning a report, Tower’s clinical experts walked the client through each recommendation, explaining how and why changes were appropriate. This transparency ensured that the payer, the defense attorney, and the treating physician were aligned before submission.

The final MSA reflected current medical necessity and included detailed documentation supporting each change. When presented to CMS, the submission received prompt approval with no development requests — a testament to the thoroughness of Tower’s process.

Why Oversight Makes the Difference

In MSA management, accuracy is everything. A single unchecked treatment plan can inflate costs by hundreds of thousands of dollars. Physician peer review adds a layer of expert validation that standard file reviews simply cannot provide. By ensuring that each projected medical service is both necessary and properly justified, Tower protects clients from avoidable financial and compliance risks.

This case demonstrates the tangible value of pairing clinical and administrative expertise. It also reinforces a key truth in the MSA industry: compliance and savings are not competing goals. When handled correctly, one strengthens the other.

Lessons Learned

Medical oversight pays off. Involving a physician reviewer early or mid-process can uncover inefficiencies that purely administrative reviews miss.
Documentation drives approval. Every modification included detailed clinical support, making CMS approval faster and more predictable.
Collaboration builds trust. Transparent communication between Tower, the client, and treating providers eliminated resistance and ensured everyone understood the reasoning behind the changes.
Savings reflect strategy. The $1 million reduction was not luck, it was the result of structured review protocols, experienced medical oversight, and Tower’s culture of precision.

Results That Reflect Expertise

Beyond the financial win, this case underscored Tower MSA Partners’ reputation for pairing clinical insight with regulatory mastery. The client achieved measurable ROI, CMS compliance, and peace of mind knowing that future medical allocations were realistic, defensible, and supported by clinical data.

Each peer review conducted by Tower is more than a medical check — it is a safeguard for payers, claimants, and settlements. This case serves as another example of how Tower delivers consistent, evidence-based results that protect both cost and care quality.

FAQs

What is a Physician Peer Review in MSA?

It is an independent medical evaluation that confirms treatment plans and medications in an MSA are clinically justified and aligned with CMS guidelines.

How does Peer Review reduce MSA costs?

By identifying unnecessary or outdated treatments and offering safer, evidence-based alternatives, peer review reduces total medical cost projections without compromising care.

Does CMS recognize Peer Reviews?

It’s important to combine the peer review with clinical oversight to document the changes to the treatment plan and medication regimen, which CMS will recognize.

When should an MSA include a Peer Review?

Any time a claim involves long-term treatment or high medication costs, a peer review should be performed before submission.