MSP Compliance Archives

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.

Opioids in the MSA… Challenges and Strategies

November 3, 2017

If seeing the word opioids one more time doesn’t trigger some sort of reaction, whether sadness, anger, desperation, or possibly hope at what appears to be traction to ‘Turn the Tide’ of addiction, then I can only surmise that you must live under a rock! That certainly isn’t the case here, as in our world of MSP compliance, the word opioids is either read, spoken or written every single day. It permeates our industry and our lives.

The most recent example of the profound impact opioids continue to have on workers’ compensation, the MSP industry, and specifically on the Medicare Set Aside (MSA), came from a study released earlier this week by the California Workers’ Compensation Institute (http://www.cwci.org). Those who saw the study became painfully aware that in the state of California,

“Nearly 70% of federally mandated and approved Medicare settlements for injured workers require funding for decades of opioid use, often at dangerously high levels and in conjunction with other high-risk drugs.”

CWCI study and key findings

The CWCI examined data from 7,926 California WCMSA plans completed, submitted and approved by the Centers for Medicare and Medicaid Services (CMS) in 2015 and 2016. To achieve a representative cross section of the state’s MSA cases, the authors compiled its dataset of 7,926 WCMSAs from four national vendors whose work product represented more than 50% of the state’s MSA market.

Overall findings were as follows:

$103,393 Average CMS approved WCMSA
$48,986 Average RX$ (47.6% of MSA)
69.4% % WCMSAs with opioids (twice the rate of any other drug class)
Norco / Vicodin were included in 44% of the opioid inclusive WCMSAs

Also significant were CWCI’s findings when the authors compared opioids found in WCMSAs to a case-matched control group of closed workers’ comp permanent disability claims for similar injuries. This comparison demonstrated that the WCMSA allocations included much stronger opioids, with average morphine milligram equivalents (MMEs) at 45 times the level used in the control group during the life of the claim. In addition, the WCMSAs with opioids required funding for an average daily dose of 54.7 morphine equivalents (MEDs) for a period of 20.9 years.

An industry’s call to action

The realization that opioids represent a major problem with the WCMSA did not come as a surprise to Tower, or to the National Alliance of MSA Professionals (NAMSAP). For the past 2 years, NAMSAP, through its Evidence Based Medicine and Data and Development committees, has been working tirelessly to educate the MSP community as to what happens in the MSA when opioids are prescribed over the life of the claim and remain as standard treatment when the MSA is prepared and submitted to CMS. NAMSAP has hosted multiple webinars to bring industry, regulatory and legislative experts together to discuss the opioid impact, and sent representatives to Washington to discuss our concerns with CMS. At our most recent annual conference, NAMSAP hosted Assistant Surgeon General, RADM Pamela Schweitzer, Pharm.D., BCACP, who shared both her concern for our situation, and her enthusiasm for our passion and our efforts.

With a singular focus among our members, I am hopeful that NAMSAP can successfully modify prescribing behavior and ultimately impact WCMSA outcomes. Unfortunately, this doesn’t benefit carriers, employers, third party administrators and injured workers today.

What are we doing now?

At Tower, the issue of opioid misuse and the importance of pre-MSA intervention has been in the forefront of our business model, our technology platform and our workflow from day 1. Our Pre-MSA Triage service identifies issues long before the MSA and provides practical recommendations to address obstacles. Our integrated technology platform tracks pharmacy triggers and interventions, escalates to our Internal Pharm. D. to contact the treating physician and diaries to track progress until treatment has been optimized. We then finalize the MSA and submit to CMS for approval.

The result of our workflow, our technology and the internal team of clinical, legal and medical experts we’ve built is a streamlined, end-to-end process that identifies issues, tracks progress and drives results for our clients.

Results achieved across all clients:

$59,070 Average CMS approved (Non-Zero) WCMSA$
58.7% CMS approved WCMSAs with $0 Pharmacy
22.6% CMS approved WCMSAs that include opioids
61.4% MSA savings through integrated Rx interventions

These are numbers we track monthly through our CMS Reconciliation Module to confirm that CMS performance continues to improve. Our belief is that until prescribing habits change and best practices in opioid treatment can be implemented and enforced, our responsibility is to drive better outcomes through both formal intervention services and consultative oversight. Our clear focus is to limit pharmacy to those medications that are appropriate for long term use, to discontinue opioids where possible and to reduce MED to the lowest level possible when opioids must be included in the WCMSA.

Conclusion

In the words of HHS Secretary, Tom Price, M.D. and Kellyanne Conway, counselor to President Trump,

“Ending the opioid epidemic will require an all hands on deck effort”.

Stay tuned.

In a Volatile Political Climate MSAs & Professional Administration Provide Much Needed Assurances

March 17, 2017

Learn why MSAs and professional administration offers stability in an otherwise volatile and partisan political environment in this joint article between Ametros Financial and Tower MSA Partners

These first few of months of 2017 have been, to put it mildly, volatile in national politics. The incoming Trump Administration and a Republican Congress are poised to tackle the federal budget, Medicaid, and the Affordable Care Act (Obamacare) among many other federal programs. All of these issues have sharp partisan divides, however no matter where your views lay on the political spectrum, if you are a professional involved in the workers compensation industry, these issues may have a big impact on how you can be successful at your job.

This article looks at what impact the Trump administration and a Republican-controlled Congress may have on Medicare Set-Asides (MSAs) in the context of the legislative and regulatory history of the Medicare Secondary Payer (MSP) Act and how the uncertainty resulting from potential changes to federal healthcare programs results in MSAs and professional administration being even more relevant in the settlement of workers’ compensation cases.

The MSP Act Has Been and Remains Bipartisan

A review of the history of the MSP Act demonstrates a noticeably bipartisan effort to improve and expand its applicability and enforcement mechanisms. The MSP Act was enacted in 1980 during President Carter’s administration. Subsequent to its passage, provisions were added over the Reagan, George H.W. Bush and Clinton administrations, all emphasizing Medicare being secondary to group and non-group health plans. The most notable legislative expansion occurred in 2007 when a Democratic-controlled Congress passed, and President George W. Bush signed into law, the Medicare, Medicaid and SCHIP Extension Act which included Section 111 Mandatory Insurer Reporting provisions for group and non-group health plans. There also continues to be a decade long effort to pass bipartisan legislation which would implement certain reforms to the Workers’ Compensation Medicare Set-Aside (WCMSA) review process. While the most recent WCMSA reform bill died in the last Congress it is expected a new bill will be reintroduced in 2017.

Besides legislative expansion of the MSP Act, during President George W. Bush’s administration there occurred the release of the July 23, 2001 CMS memo, commonly called the “Patel Memo.” The Patel memo and subsequent CMS memos effectively formalized a process for CMS to review and approve WCMSAs.

MSA reviews continued, Medicare conditional recovery processes expanded and Section 111 was implemented all during the course of President Obama’s administration. The only legislative change to the MSP Act occurring during the Obama years was the passage of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act) which was a successful bipartisan effort to address deficiencies identified in the MSP Act, particularly Section 111 reporting and Medicare conditional payment recovery.

Since the enactment then of the MSP Act in 1980 it has continued to be expanded and enforced consistently across both Republican and Democratic Presidents and Congresses.

Why has there not been a partisan divide? The simple reason is that the MSP Act forces entities other than the federal government to pay which has benefits for both political parties. For Democrats it demonstrates their protecting the viability of a federal government entitlement program while for Republicans it demonstrates their protecting taxpayers by shifting costs away from the government. While the Trump administration has to our knowledge never issued any MSP policy statements, based upon the past bipartisanship on this issue, our expectation is the administration will continue and possibly expand the MSP compliance programs at CMS.

Uncertainty Over Federal Healthcare Programs to Drive Assurance with MSAs

President Trump has indicated repeatedly that he will not reduce benefits to Medicare beneficiaries. Nonetheless, Medicare beneficiaries are facing premium increases. Notably, a Kaiser Family Foundation report indicated Part D premiums are rising by an average of 9% in 2017. As for Medicaid, the Trump administration is supporting a block grant program which would give more discretion to the states in formulating and implementing their own Medicaid programs compared to the present process which includes significant federal oversight. Finally, and most significant, is the Republican-led initiative to “repeal and replace” the Affordable Care Act, commonly known as ObamaCare. These potential changes to statutory programs create uncertainty for injured workers contemplating settlement of medical in their workers’ compensation cases.

Uncertainty for injured workers exists with programmatic changes to Medicare and private group health plans which are increasingly driven by a more value-based approach to healthcare delivery. A value-based approach provides incentives to medical providers to be more cautious with prescribing treatments and medications which may have limited value to the patient. This is also usually tied in part to a utilization review process which places limits on care through the use of evidence-based medicine. While in the past some injured workers have settled medical stemming from their work related injury confident that they could shift their ongoing work-related care, if any, to their group health plan, such coverage may now be limited. And when it comes to shifting costs to Medicare, CMS’s long-standing policy is such costs must be accounted for in an MSA.

MSAs and professional administration A Flight to Certainty

Accordingly, injured workers and their attorneys when settling their workers’ compensation cases will look for certainty where it can be obtained so that they have the assurance of access to medical care for their future injury-related care. For claimants who are Medicare beneficiaries or are close to becoming Medicare beneficiaries, such assurance can be obtained by a properly allocated MSA which is CMS-approved, when necessary, and professionally administered to maintain the MSA funds over life-expectancy in compliance with CMS rules.

Tower MSA Partners is committed to providing employers and claimants a reasonable MSA allocation which, along CMS guidelines, properly accounts for future injury-related and Medicare-covered medical care without unnecessary overfunding. This often includes Tower MSA reaching out to treating physicians to confirm current care regimens or clarity regarding ongoing medication and treatment prior to submission of the MSA to CMS.

While CMS approval of the MSA and subsequent funding provides assurance at the point of settlement that funds for injury-related medical have been provided, equally important is proper administration of those funds such that an injured worker can be assured the funds for his or her care will last over their life expectancy and that there will be a seamless transition to Medicare for payment if the funds every run out.

Ametros’ professional administration service, CareGuard, secures the injured party discounts on their medical treatment, and prescription costs. All the while they are free from utilization review allowing them to not have to worry about their treatment being rejected. Additionally, CareGuard will makes sure all MSA expenses are accounted for in the eyes of Medicare. Cost-effective programs like CareGuard are in place to protect the injured worker post-settlement and ensure compliance with CMS requirements for MSA administration.

In this current era of high uncertainty, all parties can rest easy by focusing on known methods to protect themselves and the injured party throughout the claim handling and settlement process. That’s why many believe it is more critical than ever to obtain an adequate MSA that will cover the ongoing medical care of the injured party and, upon settlement, to have a professional administrator help the injured party make the funds last as long as possible and do all the required Medicare reporting.

For further information or questions om MSAs and professional administration, please contact:

Tower MSA Partners
Dan Anders (847) 946-2880 or Daniel.anders@towermsa.com

Learn more at: www.towermsa.com

Ametros
Porter Leslie – (339) 223 9857 or pleslie@ametroscards.com
or
Jayson Gallant – (339-234-3420) or jgallant@ametroscards.com

Learn more at: www.ametroscards.com

Workcompcentral Highlights Tower MSA CEO Rita Wilson’s “Edge” in MSP Compliance Technology

December 20, 2016

Tower MSA Partners CEO, Rita Wilson, is the subject of a recent Workcompcentral article, Focus on Tech Has Guided MSP Compliance Co. CEOs Career, highlighting how Rita’s career in building better pharmaceutical and worker’s compensation technology systems led her to develop a Medicare Secondary Payer (MSP) technology platform which electronically integrates medical and cost-containment information.

In discussing why the MSP compliance technology platform is a difference maker for Tower MSA, Workcompcentral’s Emily Brill quotes Rita:

Tower MSA has differentiated itself by building out a software system that monitors and shares claim information from beginning to end, integrating medical and cost containment information for “continuity” and to avoid “reinventing the wheel” by scrambling to get information from separate sources.

The article further quotes Rita in explaining how the platform assists Tower MSA in providing MSP compliance services to its clients:

Our technology platform is able to track claim information all the way through, through the conditional payment research process, through the intervention process, through the MSA process. What we did was integrate this information and track it with one software application that allows us to measure the progress each month, and determine when the right time to finalize the MSA.

In understanding the benefits of Rita’s focus on technology in MSP compliance, Ms. Brill spoke to Ann Schnure, the former Vice-President of Risk Management for Macy’s, and also a strong proponent of the use of technology in claims handling, who said of Rita:

Wilson’s focus on technology has always given the CEO an edge.

Learn more about Tower MSA Partners Chief Executive Officer Rita Wilson, connect with her on LinkedIn and view her blog posts on our MSP Compliance Blog.

To learn more about how Tower MSA Partners’ technology platform can give you an “edge” in Medicare Secondary Payer Compliance please contact Rita Wilson at rita.wilson@towermsapartners.com or 888.331.4941.

FDA Mandates New Warnings for Opioid and Benzodiazepines

September 20, 2016

In a statement released on September 1, 2016 (FDA Black Box Warning), the Food and Drug Administration (FDA) announced that “after an extensive review of the latest scientific evidence, it is requiring class-wide changes to drug labeling, including patient information, to help inform health care providers and patients of the serious risks associated with the combined use of certain opioid medications and a class of central nervous system (CNS) depressant drugs called benzodiazepines.”

Background

Benzodiazepine medications are most commonly prescribed to treat anxiety and mood disorders, such as depression and insomnia. The drugs also are used to treat seizures. According to the FDA, the number of individuals who were prescribed both opioids and benzodiazepines grew by 41 percent, or 2.5 million, between 2002 and 2014.

States submitted a petition to FDA calling for the agency to add black-box warnings about the potentially fatal combination of opioid painkillers and benzodiazepines to the drugs. The officials said prescription opioids and benzodiazepines often are used together, and data show that almost one in three unintentional overdose deaths from prescription opioids also involved benzodiazepines.

What drugs are impacted?

The agency is requiring that black box warnings, the strongest available, be added to nearly 400 products (of which more than 200 are opioid painkillers) alerting doctors and patients that combining opioids and benzodiazepines can cause extreme sleepiness, slowed breathing, coma, and death.

The FDA is warning patients and their caregivers about the serious risks of taking opioids along with benzodiazepines or other central nervous system (CNS) depressant medicines, including alcohol. Serious risks include unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, coma, and death. These risks result because both opioids and benzodiazepines impact the CNS, which controls most of the functions of the brain and body.

The bigger picture

The agency said the move is one of a number of steps the FDA is taking as part of the agency’s Opioids Action Plan, which focuses on policies aimed at reversing the prescription opioid abuse epidemic, while still providing patients in pain access to effective and appropriate pain management. For those who may not know what’s in play or want more information about the national effort, go to TurnTheTideRx.Org to access the U.S. Surgeon General’s plans to curb the epidemic.

In responding to the announcement, FDA commissioner Robert Califf noted, “It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together,” He further added, “We implore health care professionals to heed these new warnings and more carefully and thoroughly evaluate, on a patient-by-patient basis, whether the benefits of using opioids and benzodiazepines … together outweigh these serious risks.”

What does this mean to you?

In dealing with workers’ compensation claims for Class I and Class II Medicare beneficiaries, the combination of opioid pain killers and benzodiazepines is a common occurrence. When we see it, we immediately notify the claims handler that this is a dangerous combination and certainly not intended for long term use. For the elderly, drug combinations such as this are even more dangerous as their effects are exacerbated due to the rate at which they metabolize in an elderly person. For those who may not be familiar, there is an excellent resource (2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults) that focuses on commonly used drugs and the risks and potential dangers when prescribed to the elderly. According to the guide,

“Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults and should be avoided”.

One of many pieces of the opioid puzzle

As stated within the “TurnTheTideRx” campaign literature, it is truly “All hands on deck” if we hope to change the course of the opioid epidemic. It will take patient, family members, friends, and in the case of workers’ compensation claims, claims handlers, nurse case managers, employers, carriers and even MSP compliance providers to help change prescribing habits. While legislative, regulatory and compliance entities can assist by setting policy, it is the physician who writes the first script. When I see that one of the largest emergency rooms in the country (One of Nation’s Largest ERs Kicks the Opioid Habit) can function without writing opioids as first line pain management for acute pain, I am convinced that a change is possible if we can engage our physicians.

We are but one piece of this very complicated puzzle, and “Big Pharma” has deep pockets. Through education of all stakeholders, advocacy to those in positions of power and influence, and our respective collaborative efforts to optimize claims and treatment, we can make a difference in the lives of our patients.

CMS to ‘Consider’ Expanding Its Review Process to Include Liability MSAs

June 10, 2016

In a News Alert released Thursday, June 9, 2016, the Centers for Medicare and Medicaid Services (CMS) announced is considering expanding its voluntary Medicare Set-Aside Arrangements (MSA) amount review process to include the review of proposed liability insurance (including self-insurance) and no-fault insurance MSA amounts. CMS plans to work closely with the stakeholder community to identify how best to implement this potential expansion. CMS will provide future announcements of the proposal and expects to schedule town hall meetings later this year.

The link to the alert can be found in the ‘What’s New’ section of the Medicare Coordination of Benefits and Recovery Overview page at CMS.gov.

https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Whats-New/Whats-New.html

Background

Signed in June, 1980,

42 U.S.C. §1395y(2)(A)) prohibits Medicare from making payment, except as provided in (B), for any item or service, to the extent that payment has been made, or can reasonably be expected to be made, under a workers’ compensation law or plan, an automobile or liability insurance policy or plan (including a self-insured plan), or no fault insurance.

42 U.S.C. §1395y(2)(B) – The Secretary may make payment under this title with respect to an item or service if a primary plan as described in Subparagraph (A) has not made or cannot reasonably be expected to make payment with respect to such item or service promptly. Any such payment shall be conditioned on reimbursement to the appropriate Trust Fund in accordance with the succeeding provisions of this subsection.

While statutory provisions included Liability cases, there were no LMSA guidelines . As a result, actions taken to comply with the MSPA statutes in a Liability case ranged from extremely conservative to strategies that earned the LMSA environment its characterization as ‘The Wild West’. Those who took the conservative route followed the CMS guidelines established for WCMSA. Other strategies ranged from making the LMSA decisions based on the severity of the injury in a liability case to doing nothing.

CMS’s Review of LMSAs

With no established thresholds for CMS submission and review, those who took the conservative path followed WCMSA guidance and attempted to submit. While certain of the CMS offices would review an LMSA, acceptance was random. Eventually, with greater acceptance and use of the WCMSA portal, CMS began to reject LMSAs. Submitters could make the effort to submit and obtain a letter of rejection.

While not a ‘safe harbor’, the attempt to submit was at least evidence of efforts to follow the guidelines.

CMS’s first attempt to address LMSAs

In June 2012, CMS began the process by releasing an Advanced Notice of Proposed Rulemaking (CMS-6047-ANPRM) to solicit public comment on how to implement an MSP process for liability settlements. The ANPRM received many public comments.

On August 1, 2013, CMS sent the NPRM to the OMB for their approval. The NPRM was never made public because the OMB did not approve it, and on 10/8/2014, this last attempt at ‘guidance’ surrounding Liability MSAs faded into the sunset whenCMS withdrew the NPRM. The reasons for the OMB’s rejection of the proposal were never made public.

Where are we now?

With the Liability TPOC mandatory reporting threshold of $1,000 beginning January 1, 2015 (and the voluntary threshold of $300), the BCRC now has access to more data on Liability claims than ever. And with the announcement of the CRC (Commercial Repayment Center) in October, 2015, and its singular focus on payer recovery, the BCRC has greater resources to pursue recovery with Liability settlements. With this combination of information and resources, it would follow that the absence of documented evidence to show that Medicare’s interests have been considered when settling a liability claim might lead to financial exposure for all stakeholders in the process…. the perfect time to introduce ‘guidance’ for the LMSA.

Tower will continue to monitor associated news on this topic and will actively participate in the TownHall Meetings regarding this topic.

Growing Press Surrounds Tower MSA’s Groundbreaking MSP Automation Suite

January 25, 2016

An article today posted by Yahoo! Finance discusses the new MSP Automation Suite by Tower MSA. The article cited the groundbreaking and sophisticated technology developed by Tower MSA that drives the MSP process.

Describing the MSP Automation Suite:

“The sophisticated technology drives all the processes Tower has perfected to proactively manage Section 111 Mandatory Insurer Reporting, the recently implemented Conditional Payment Notice process, and to stage workers’ compensation claims for Medicare Set-Asides and closure.”

Our CEO Rita Wilson offered many insights about the new MSP Automation Suite:

“Essentially, it automates our best practices for Medicare Secondary Payer compliance, claims optimization and MSA preparation.”

“Our Pre-MSA Triage identifies barriers to settlement and recommends claim-specific interventions, like physician peer review and clinical oversight, to remove those barriers long before preparing an MSA.”

“Clients don’t need to manually diary activities or call to check on things.”

“The system shows exactly when a phone call was made, and follow-up is due.”

“Automation frees claims professionals to address issues that require a human touch.”

The article went on to say:

“The MSP Automation Suite can track a claim from Medicare beneficiary identification through final settlement. It records every claim activity performed by Tower or its network of practicing physicians and pharmacists and provides clients with 24/7, end-to-end visibility into claims. The system prompts for missing data, conditional payment searches, and medical/pharmaceutical interventions and sends electronic updates to clients at appropriate data points.”

If you would like to read the full article, it is available here on Yahoo! Finance.

Pre-MSA Triage Works!

November 17, 2015

Inappropriate and/or unnecessary prescription drugs, along with recommended medical procedures that are recommended, but never performed, are all too common in workers’ compensation claims. Yet they are often overlooked when moving a claim to settlement. But a new tool is helping payers identify and address obstacles, saving millions of dollars in MSA and settlement costs. Several recent cases bear out the program’s success.

Tower MSA Partners developed this unique service to ensure MSAs include only accurate and appropriate medical and pharmaceutical treatment. The Pre-MSA Triage allows payers to stage claims for optimal outcomes by providing a snapshot of MSA exposure before the MSA. By following our recommended interventions, clients are achieving CMS approval of reduced MSAs, with reductions of more than 50% in many cases.

How it works

Tower analyzes 6 months of medical records to identify care and cost issues, including the projected MSA cost of a claim based on the current medical and pharmacy treatment regimen. The review also provides a snapshot view of the MSA exposure in a non-discoverable (not an MSA) format, and offers an overview of inappropriate, unnecessary treatment and cost drivers that may impact MSA and settlement. For example, the review may uncover denied injuries and/or body parts, recommended surgical procedures that were never pursued, spinal cord stimulators that were recommended but never evaluated, gaps in treatment dates, unrelated medications, and off-label drug usage.

We then recommend various interventions, such as physician peer review, clinical oversight and conditional payment searches/negotiations to effect improved outcomes and savings in the overall claim costs, frequently as much as 50 percent!

Example Case Study

Tower’s Pre-MSA Triage projected the MSA cost for a 46-year-old male at $1,300,000. More than $1,000,000 of the total projection was due to extended prescribing of both long and short acting opioids. Tower recommended a Physician Peer Review followed by direct dialogue with the treating physician. Agreement to wean was obtained in writing and Tower initiated its clinical nurse oversight service to track progress.

Through Tower’s MSP Automation Suite, developed and maintained internally, we were able to drive the weaning process with the physician through tracked monthly calls, and to guide the adjuster as to when discontinued medications should be blocked by the client’s PBM.

Upon finalization of the weaning process, Tower worked with defense to obtain the necessary written language from the treating physician to confirm discontinuation and remove past medications. The final MSA was submitted and approved by CMS for $210,641 – a savings of more than $1,000,000 from the original estimate!

Conclusion

The example provided here is one of many success stories we are seeing, and through our MSP Automation Suite, we’ve been able to manage the process from triage through final CMS submission and approval in a secure, digital environment. Whether handled internally by our team of nurses or through a formal intervention and peer dialogue by one of our physicians, our system drives every step in the process.

Many companies can identify problems, and some even make recommendations. At Tower, we believe the key to successful MSA outcomes is a proactive approach to identify, intervene and remain involved through closure.

Is The Tidal Wave of CMS Development Letters Behind Us?

May 14, 2014

In case you didn’t hear us shouting from the rooftop, Tower MSA Partners (as well as other companies across the MSA industry) was notified Tuesday, May 13, 2014 that full MSA approval had been given for approximately 100 cases, more than 50 of which were in various stages of development request processing. While this was certainly a welcomed announcement, I believe strongly that it was not an arbitrary decision by CMS, nor was it achieved by a few large companies. I see this accomplishment as the result of the combined and focused efforts of many in the MSP compliance industry.

Where Do I Begin?

As many of our clients have become painfully aware, development requests have been a major issue for Tower, as well as every carrier, employer and MSA provider in our industry, since late 2013. In early January, I discussed this new trend via a blog article (http://www.mspcomplianceblog.com/cms-wcrc-development-letters-essential-information-or-delay-tactic/ ) to explain what we were seeing as a company. In follow up to the article, I took this information to my industry peers, encouraging their participation to track the trend through my involvement with the Data and Development Committee of NAMSAP (National Alliance of MSA Professionals).

An Industry Moved to Action

Data capture of development requests began in January with analytics by the DDC for the next 90 days. At the same time, the NAMSAP Board of Directors asked that I prepare an article to be published in NAMSAP’s national newsletter, and also to help author a letter to be submitted to CMS on behalf of the NAMSAP BOD. The article’s intent was to communicate the source and impact of development letters among our membership, and to encourage readers to share their experiences in the form of actual data. The letter to CMS presented aggregated, experiential data to demonstrate the effects of the WCRC’s actions, and to communicate the settlement obstacles being created by this process (not the least of which was the request for HIPAA protected primary care physician medical records).

Communication Through Data Analytics

Through the efforts of the DDC to summarize the data obtained from multiple companies across our industry, the letter submitted by NAMSAP’s BOD to CMS provided clear evidence of the impact of the actions of the WCRC on settlement initiatives. We then requested that CMS work with our industry to reestablish a strategy that included only ‘injury related’ medical and pharmacy history, and followed the published standards defined in the March 2013, November 2013 and February 2014 editions of CMS’s own WCMSA Reference Guide as their only criteria to ensure that Medicare’s interests are adequately protected.

While we cannot confirm that CMS’s recent actions were in response to the initiatives pursued by NAMSAP, or through the efforts of a single company, we certainly believe industry involvement for the benefit of all stakeholders was the right course of action and are thrilled with the outcome. We are pleased to have been an active participant in this process.

Lessons Learned?

As the MSP compliance partner for employers, TPAs and carriers, our primary responsibility is to prepare and submit Medicare Set Asides that to the best of our knowledge, ability and expertise ensure that Medicare’s interests are adequately protected when settling future medical claims. From a professional ethics perspective, this means doing what is reasonable on behalf of the claimant. For Tower, we describe this as, “helping clients balance care, cost and compliance when settling claims that involve Medicare beneficiaries”.

One of our client’s website taglines reads as follows, “We strive to ensure that injured workers get the right care at the right time—and we focus on getting it done the right way. It’s our commitment.” I’ve read this quote many times and strongly believe this is the goal of most in our industry….. do what is reasonable. And in the end, regardless of CMS submission and approval, I believe this will provide adequate evidence of our efforts to protect Medicare.

Looking ahead, we must now prepare our team and our clients for the next wave of CMS submissions. How do the experiences of the past 6 months impact our internal processes going forward? Was the development letter barrage truly a ‘ghost hunt’, or is there something to be learned from the WCRC’s actions? This will be the focus of our attention in the coming weeks.

CMS New WCMSA Decision Memo: TENS Units: Not Appropriate for Chronic Low Back Pain

October 5, 2012

Tens units not appropriate for low back pain

The Centers for Medicare and Medicaid (CMS) issued a new memorandum that will affect pricing determinations for TENS (Transcutaneous Electrical Nerve Stimulation) units for the treatment of Chronic Low Back Pain (CLBP) included within the Workers’ Compensation Medicare Set-Aside (WCMSA) that have been submitted to CMS for approval.

On June 8, 2012, CMS issued a new Decision Memo that defined CLBP as “an episode of low back pain that has persisted for three months or longer; and is not a manifestation of a clearly defined and generally recognizable primary disease entity.” CMS further stated that a TENS unit was not “reasonable and necessary for the treatment of CLBP under section 1862(a)(1)(A) of the Social Security Act.”

TENS is the use of stimulating pulses across the surface of the skin produced by a device to stimulate the nerves for therapeutic purposes. TENS help stimulate your body to produce higher levels of Endorphins. The TENS units are small, battery operated devices that deliver these stimulating pulses across the surface of the skin. It has been an ongoing dispute over the years as to whether TENS units do more than act like placebo’s, and whether they actually treat and cure CLBP.

CMSs New Pricing Determination will affect the WCMSA’s proposal as follows:

Workers’ Compensation cases settled prior to June 8, 2012:
“For those Workers’ Compensation cases settled prior to June 8, 2012, and where the settlement included pricing for TENS for CLBP, CMS will consider funds spent for TENS for CLBP by beneficiaries and claimants as being an appropriate expenditure of funds as part of the WCMSA.”
Workers’ Compensation Cases Settled After June 8, 2012:
“For those Workers’ Compensation cases that were not settled prior to June 8, 2012, and where the WCMSAs proposal includes funding for TENS for CLBP as part of the WCMSA, CMS will re-review the cases and remove pricing for TENS for CLBP. (Regional Offices shall obtain from Submitters requests for a case re-review, along with a signed statement indicating a settlement had not occurred prior to June 8, 2012.)”

It is important to note that in the event CMS does re-review a WCMSA for removal of a TENS unit for CLBP, the claimant may NOT use the funds from their WCMSA to pay for the TENS for CLBP. If a claimant uses the funds for the TENS, this would result in an inappropriate expenditure of funds.

For additional questions on the use of TENS units as treatment for chronic low back pain, and its implications on future medical treatment and the WCMSA, please contact Tower MSA Partners at 888-331-4941 or email us at info@towermsa.com. For the full text of the CMS Decision Memo, see Decision Memo for Transcutaneous Electrical Nerve Stimulation (TENS).