Tag: NAMSAP

NAMSAP Bulletin Highlights Meeting with CMS on Liability MSA Reviews

August 16, 2018

man holding transparent icons of people with stakeholder in the center

Recently, the National Alliance of Medicare Set-Aside Professionals (NAMSAP) released a Special Edition Bulletin providing insight into a meeting between CMS and NAMSAP representatives on the topic of the planned expansion of the Workers’ Compensation MSA review process to liability MSA Reviews.  NAMSAP’s April 2018 meeting was one of several with stakeholder organizations.

Your writer was one of the NAMSAP representatives who had the privilege of meeting with CMS to hear and discuss how such a Liability MSA Reviews may work.   Mr. Tom Stanley, the Co-Chair of NAMSAP’s Liability Committee provided a summary of the following meeting highlights in the bulletin:

  • CMS stated they have an 18-month timeframe (from April 2018) before it rolls out a LMSA Review program.
  • The program would be voluntary.
  • CMS has indicated that their enforcement mechanism is the denial of services.
  • CMS felt strongly that the injured party must receive something (free and clear) through settlement.
  • CMS would not review an LMSA until Settlement has been reached.
  • CMS feels a LMSA is exclusively the responsibility of the plaintiff.
  • Regarding LMSA’s, CMS made it clear that the defendant(s), and their insurers, are not a target.
  • Medicare pricing of services was discussed.
  • CMS does not feel it can mandate professional administration.
  • CMS would publish a LMSA Reference Guide.
  • Eligibility remains the same as the current WCMSA system – Medicare beneficiaries or injured parties who have a reasonable expectation of Medicare eligibility within 30 months. Per statute, Medicare’s interest must be considered in every claim.
  • A workload threshold of $250,000 is anticipated – “NO SAFE HARBOR”. This level mirrors the $25,000 workload threshold for WCMSA’s.
  • For settlements between $250,000 and $750,000 threshold, CMS approval is available and encouraged by CMS. CMS would apply “a formula” to determine the LMSA amount. Starting with the total settlement amount, CMS would subtract certain expenses and apply the discount factor to total settlement.
  • Above $750,000 level is a full commutation. A traditional MSA would be prepared and, if submitted to CMS, evaluated by CMS for adequacy.

As Mr. Stanley advised, “everything discussed in the meeting was subject to change and related to liability Medicare Set-Asides only.”  I would like to emphasize that point as well.  You should not in anyway take the above points as final, rather they are points of discussion as CMS continues to listen to stakeholders and assess the best method for protecting Medicare’s interests in post-liability settlement injury-related medical.

Importantly, CMS realizes that in protecting those interests an eventual voluntary LMSA review process must continue to provide an incentive for the parties to settle their case.   Consequently, some type of apportionment to ensure the plaintiff receives a portion of the settlement monies is expected in any final review process.

NAMSAP will to continue to dialogue with CMS and also discuss with its membership, both through a webinar and at the annual conference, the points presented by CMS.  Given the launch of a CMS LMSA review process is not expected for some time, Tower MSA Partners will shortly be releasing a white paper on best practices for addressing future medicals in liability settlements.

If you have any questions or would like to discuss the topic of LMSAs further, please contact Dan Anders, Chief Compliance Officer, at 888.331.4941 or Daniel.anders@towermsa.com.

Related:

Liability Settlement Solutions

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.

Opioids in the Life of the MSA… Coming Soon

June 10, 2016

In a statement released on June 7, 2016, the National Alliance of Medicare Set-Aside Professionals (NAMSAP) announced the 2nd in a series of webinars focused on opioid drugs in the Medicare Set Aside.  The release can be found at NAMSAP Presents “Opioids in the Life of the MSA” Webinar on June 21

 Background

Since the creation of NAMSAP’s Evidence Based Medicine Committee in 2014, opioid use has been in the forefront of attention within NAMSAP.  As a member of NAMSAP’s Board of Directors, I have participated in our organization’s efforts to collaborate with experts on this critical issue, to educate our members as to what is happening when opioid involved MSAs are reviewed by CMS, and now to advocate to entities outside of workers’ compensation.

Our goal is to publicize the conflict between the WCMSA review process and  CMS’s own criteria for opioid addiction triggers, prior authorization requirements and mandatory weaning.   This release explains the rationale and basis for our request: NAMSAP has called for CMS to limit opioids in the MSA review;

The easy answer

Many say the answer to the inconsistencies in the WCMSA review process as it relates to opioids is to stop submitting the MSA to CMS.  “Why feed into a broken system?” is the question I’ve heard.  If opioids aren’t appropriate for life expectancy, if addiction is imminent, if weaning is appropriate, then include this in the MSA and just don’t submit.

I absolutely endorse CMS non-submission as an option.  Where I may differ from others is that I believe it should be decided based on the facts of the case as compared to the objective and subjective nature of CMS’s review and approval process.  Unfortunately, I fear a corporate non-submit strategy is a slippery slope down the path of massaging the MSA to ‘fit’ the needs of the moment.  That is not its intent of the MSA, nor will it be left unchallenged in the long term.

What if?

I believe the prevalence of opioids in workers’ compensation indicates something is broken, but the break is much further up the food chain.  Can and should CMS ‘fix’ a problem that we have allowed and enabled over the life of the claim?  Can an excise tax on opioids fix the problem?

What if we looked at things differently?

  • What if we identify the physicians who don’t write for opioids as first line treatment for pain?
  •  What if we know and use the physicians with a proven track record of getting patients back to work
  •  What if we implement triggers to identify initial onset and changes in opioid dosage and frequency?
  • What if an increase in Morphine Equivalent Dosage was measured and addressed immediately with the physician?
  •  What if we leverage PBM reports and tools to block opioids based  on corporate designated criteria, and then execute an action plan?
  •  What if we use jurisdictional options like UR, IMR, challenging treatment to force dispute resolution and state options to allow the carrier to control physician choice where these options exist?

What if?

Working both sides

Every company has its own strategies to address the opioid issue.  Our policy at Tower is to ask every ‘what if‘ question possible as we work with clients throughout the claim and settlement process.  Whatever the answer, whether it’s physician follow up to track weaning, a formal physician peer review to challenge inappropriate treatment, or negotiating a Conditional Payment Notice to dissociate unrelated treatment, our MSP Automation Suite drives and tracks every step in the process.  We push the claim to optimize outcomes and acknowledge when the MSA is ‘ready‘ to submit.

The result of the combined efforts of all stakeholders in workers’ compensation, according the WCRI report on opioids released on June 9, 2016 is that the industry has made positive strides to address opioid issues.  Now NAMSAP is challenging CMS to modify the WCMSA review criteria so that it more closely mirrors its own Part D approvals process.

I hope you will join the webinar as we look at the policy side of the opioid issue within the MSA and that you join our advocacy efforts.