Tower MSA Partners Archives

Automation has its place, but it can’t replace people in MSP compliance

October 3, 2022

Automation in MSP compliance cannot replace human expertise in complex claims

Technology isn’t everything. It may seem hard to believe that I have said this because most of my career was steeped in technology.

In my past life, I developed automation systems for pharmacies and workers’ comp pharmacy benefit management (PBM) models. Rules-based adjudication platform allowed for automatic Rx fills for many prescriptions, but also supported trigger-based escalation for the outliers to request authorization or have an expert take a closer look. The time saved and convenience provided were astounding.

When we started Tower, Kristine Dudley and I automated much of the paper-intensive world of Medicare Set-Asides, and also integrated the 3 major components of Medicare Secondary Payer compliance, Section 111 Mandatory Insurer Reporting, Conditional Payments and Medicare Set Asides, into a single platform. I believe we were the first to do that.

Our platform, Tower’s MSP Automation Suite, was built based on state workers’ compensation statutes overlayed with WCMSA guidance, metrics-based KPI tracking and intervention / escalation triggers that supported MSP best practices. By seamlessly integrating Section 111 reporting, conditional payment resolution, and MSA preparation into a single, all-encompassing system, our MSP Automation Suite ensures that nothing drops through the cracks, no field goes unpopulated, problem cases can be identified, and deadlines are met.

Tower’s MSP Automation Suite captures, stores and manages all data points, integrates with ANY claims system, enables clients’ business rules to be overlaid onto ours, and gives our clients end-to-end visibility into Medicare and claim information. Our system also leverages embedded triggers to escalate medical and pharmacy issues, prompting a review for intervention. In short, Tower’s MSP Automation Suite leverages the best of automation until technology intersects with the need for expertise. This allows our team to manage, track and drive MSP compliance from the moment a Medicare beneficiary is identified through the claim’s closure.

Do we love automation? You bet we do.

But we realize automation can’t do everything. MSP compliance has always – and will always – require a high degree of consultative expertise. You can’t just capture and populate data fields, and automatically “pop” out an MSA that supports aggressive cost mitigation that is both CMS-approvable and facilitates settlement.

While many workers’ compensation claims move through the system seamlessly, others are “messy”. Body parts may be denied, additional claims may exist, co-morbid conditions may complicate treatment, surgeries, medical treatment and medications may be prescribed inappropriately or ICD10 codes may be too general or inconsistent with the treatment being paid by the carrier. These are just a subset of the rules-based triggers built into our system so that claims warranting attention are automatically escalated to a human expert to dig through files, examine causation questions, and probe open-ended medical care and contradictory medical records.

Clients need their calls, emails and questions answered by real people, and quickly. Complex conditional payment matters call for conversations … with a knowledgeable partner who shares your goals.

Our automated system escalates medical and pharmacy issues, but then you need a professional with specialized knowledge and experience to recommend the best intervention. And to implement it.

One of our most effective interventions created by Tower is our Physician Follow-up. Guess what? This is performed by people, people who have the patience and commitment to keep trying to talk to the provider. If you’ve tried to call and talk to your own doctor lately, you know what a challenge this can be.

These professionals have the knowledge and soft skills needed to delicately point out vague notes and open-ended recommendations in medical records. And they must be able to persuade the provider to clarify their treatment and prescriptions. Drafting a jurisdiction-specific statement for the provider to sign requires yet another human skill set.

If I had to name the one aspect that drives Tower’s success, I’d have to say service. Our technology enables us to respond quickly, anticipate issues, and proactively address them, but it’s the people, their attitudes, and their expertise our clients value the most.

The common thread in our client testimonies are service and partnership. Clients are “very impressed with [Tower’s] level of communication and availability to help answer questions,” and they say, “they truly listen; listen to understand and not just to respond.”

Perhaps this person sums things best: “They have advanced technology and certified specialists to ensure no stone is unturned.”

Insurance carriers, self-insureds and TPAs are dealing with shortfalls in staffing. There’s more pressure on the experienced adjusters, and the new hires need all kinds of support to get up to speed on MSP matters. Tower MSA Partners is here to help. That’s what the Partners part of our name means.

We are proud of our technology, and we recognize when to leverage it and when automation must give way to consultative expertise. There is a need for partnership with real people who care about your claim closure and settlement and can ensure that happens with the right balance of care, cost and compliance.

If you have any questions or just want to talk about partnership opportunities, the expertise of our people, or our technological capabilities contact me at rita.wilson@towermsa.com.

Tower MSA Partners’ WCI-TV Interviews Reveal How Workers’ Compensation Companies Use Claims Data

August 19, 2022

The workers’ compensation industry has extolled the promises of data analytics and automation for years.

But how are organizations really using claims data? What strategies have worked best? And what have they learned? Several executives will share their experiences during WCI-TV interviews sponsored by Tower MSA Partners.

Guests include Dave Strange, the Yellow Corporation’s Workers’ Compensation Manager and Greg Hamlin, Senior Vice President, Resolution with Berkley Industrial Comp. Ametros CEO Porter Leslie and Alisa Hofman, Vice President of Workers’ Compensation and Medicare Practices for Arcadia will discuss the use of data during and after settlement.

In addition, Tower’s Chief Compliance Officer Dan Anders and Chief Operations Officer Kristine Dudley will share how the technology driven company uses data to streamline Medicare Secondary Payer compliance, protect clients from penalties, and optimize Medicare Set-Asides.

Tower has been the exclusive sponsor of WCI-TV since it first aired in 2015. WCI-TV airs throughout the convention center, in hotel guest rooms and shuttles, on You Tube and CI’s website. Tower’s interviews will also be shared on the company’s LinkedIn page.

The 76^th Annual WCI Conference will be held August 21-24 at the Orlando World Center Marriott. For more information, please see https://www.wci360.com/conference/.

Is a CMS-approved $0 MSA Still Possible?

July 26, 2022

WCI TV interviews on workers compensation claims data analytics and insights

A common question we receive is whether a CMS-approved $0 MSA is still possible. The answer is, yes– if it meets the criteria.

There are three different ways a $0 MSA can be obtained, each with its own criteria and documentation requirements.

Denied Claim $0 MSA

This is a $0 MSA based on a completely denied workers’ comp claim when no payments have been made for medical treatment or indemnity. In certain jurisdictions, such as California, some medical payments can have been made during a statutory investigating period. Payments for non-treatment purposes such as IMEs, case management and medical records copies do not impact the ability to obtain a $0 MSA approval.

This type of $0 MSA has significant documentation requirements:

1. Claim Payment History

A claim payment history printout, even if blank, representing payments since the inception of the claim. All payments must be itemized.
Printout must be divided into categories for medical, indemnity and expenses with subtotals for each category and a grand total listed. This printout needs to include the print or run date.
If the claim payment history does not meet the above requirements, then Tower will work with you to identify alternative documentation that meets CMS requirements.

2. Draft or final settlement documents and court orders or rulings or a statement that no such documents exist (see below Financial Detail and Denial Letter). CMS recently added a requirement that there must be a proposed or agreed-to settlement. Importantly, while CMS requires a proposed settlement, it will reject the $0 MSA if the settlement is finalized, for example with court or commission approval, before CMS’s review and approval of the $0 MSA.

3. First Report of Injury or a statement that no such document exists (See below Financial Detail and Denial Letter).

4. Financial Detail and Denial Letter – At the time of submission Tower will draft a letter for the client to sign that confirms the denial of the claim and any other necessary explanations, such as why no First Report of Injury is available.

5. Medical Records: As with a regular MSA, medical records for the past two years must be provided with the submission.

6. CMS Consent to Release form executed by the claimant.

Accepted Claim $0 MSA

This is a $0 MSA based on medical documentation supporting no further need for injury-related treatment. In the WCMSA Reference Guide, CMS provides as follows:

The individual’s treating physicians conclude (in writing) that to a reasonable degree of medical certainty the individual will no longer require any Medicare-covered treatments related to the WC injury.

In practice, CMS accepts treating physician statements that say the injury-related treatment has resolved or returned to baseline (when there was a pre-existing condition) and that no further injury-related treatment will be necessary as sufficient to support the $0 MSA.

Keep in mind that CMS will not accept the physician’s statement unless it is consistent with the treatment records/notes. For example, if the physician states the injury-related has resolved, but treatment notes document ongoing pain to the relevant body part, CMS is unlikely to approve a $0 MSA. Also, if the injured worker will require a revision or replacement to a body part, e.g., a knee replacement, a $0 MSA will not be approved.

In addition to the physician statement, a claim payment history, medical treatment records and an executed Consent to Release are required.

Judicial Decision $0 MSA

CMS will accept a judicial decision after a hearing on the merits of the case as a basis for a $0 MSA. This can be on a completely denied claim where the judge upholds the denial of the claim or an accepted claim where the judge finds future medical treatment, if any, is unrelated to the work injury. The key here is the decision is “on the merits.” If it in any way looks like an agreement between the parties and the judge just stamped their approval, CMS will not accept it.

In addition to the judicial decision, a claim payment history, medical treatment records and an executed Consent to Release are required.

While there are strict documentation requirements, these $0 MSA approvals remain available for workers’ compensation cases meeting the applicable criteria. Please contact Tower MSA Partners at referrals@towermsa.com or (888) 331-4941 to refer a claim meeting these requirements or for further consultation.

MSA Webinar | Specialty Issues in Medicare Set-Asides

July 5, 2022

Webinar Graphic | Tower MSA Partners MSA webinar on specialty Medicare Set-Aside issues

Not all Medicare Set-Asides (MSAs) are the same. There are specialty areas for unusual cases and many questions about these.

Topics Covered in the MSA Webinar

Criteria for successful $0 MSA approvals
Whether to include PQMEs, AMEs, IMEs in the MSA
Use of court orders to limit medical care in the MSA
When and how to use the MSA Amended Review process
Correct verbiage for treating physician statements

Practical Guidance for Claims Professionals & Attorneys

Claims professionals and attorneys often receive conflicting or unclear information around these topics and other matters that make not only working with the MSA but the whole settlement process, tricky.

Learn From Tower MSA Partners’ Chief Compliance Officer

Tower is pleased to feature our Chief Compliance Officer Dan Anders, who will share tricks of the trade at a webinar on Wednesday, July 20, at 2:00 PM ET. Dan has written and submitted thousands of MSAs to CMS for almost two decades. His unique knowledge is an asset for anyone who uses an MSA in a case settlement.

Register for the MSA Webinar

A Q&A session will follow the presentation, and you can provide questions at the time you register. Please click the link below and register today!

REGISTER HERE

Tower MSA Partners Saves $175K With Optimized MSA

June 15, 2022

Tower MSA Partners optimized MSA savings for complex workers’ comp settlement

Challenge

Tower was engaged to prepare an MSA for a 54-year-old partial quadriplegic. Several issues made it difficult to prepare an accurate allocation. These included limited current medical records, erratic patient behavior, inconsistent provider treatment coding, and unknown treatment outside the workers’ compensation plan.

The preliminary MSA amount was $424,528.

Solution

Tower’s medical experts reviewed the treatment records and identified several areas where Medicare-covered expenses could be reduced through Tower’s Optimized MSA process.

At Tower’s request, the client obtained current medical records. Tower’s clinical team then reviewed those records along with the billing codes used for each treatment.

The team compared the provider’s treatment methods against Medicare reimbursement requirements. This review showed that some items could be priced more accurately with alternative codes.

For example, Tower determined that catheterization code A4353 had been used incorrectly. By using the correct billing code and applying other cost-saving strategies, Tower significantly reduced the MSA allocation.

To support CMS review, Tower explained why the original billing code was incorrect. Tower also provided the corrected coding for consideration.

Results: $175,867 in Savings

After the optimized MSA was finalized, Tower submitted a total allocation amount of $248,661 to CMS for review and approval.

CMS accepted the proposed MSA amount and issued a Full Approval.

Using Tower’s proprietary processes and technology, the client carrier reduced the Medicare exposure of the settlement. The final result was $175,867 in total savings.

Dan Anders Quoted in Claims Journal on Non-Submit MSAs and Section 111 Penalties

March 24, 2022

Article Image | Dan Anders quoted on Section 111 penalties and non-submit MSAs

CMS is serious about protecting Medicare’s funds. For years, the agency had policies that were not always enforced. These included sizeable civil monetary penalties for failure to comply with Section 111 reporting rules. They also included denying payment for medical treatment when another payer was responsible.

But things are changing. CMS has denied payments and has taken steps toward collecting those penalties.

Claims Journal Quotes Dan Anders on CMS Enforcement

Claims Journal Editor Jim Sams explores these actions in a recent article, which quotes Tower MSA Partners Chief Compliance Officer Dan Anders.

Why Section 111 Penalties and Non-Submit MSAs Matter

Section 111 reporting rules and non-submit MSAs are important compliance issues for insurers, claimants, attorneys, and claims professionals.

As CMS increases enforcement activity, parties involved in workers’ compensation settlements need to understand how reporting, Medicare payment responsibility, and MSP compliance may affect claim outcomes.

Read the Full Claims Journal Article

Read the full Claims Journal article here:

CMS Rules on Settlement Reporting May Sting Insurers and Claimants Both (claimsjournal.com)

Tower’s Dan Anders Reviews MSP Policies and Predicts 2022 Actions

January 20, 2022

Dan Anders reviews MSP policy updates and Medicare Set-Aside trends in this article

WorkersCompensation.com’s Nancy Grover captured the thoughts of Tower MSA Partners Chief Compliance Officer Dan Anders on a variety of Medicare Secondary Payer and Medicare Set-Aside issues from 2021 and 2022 in a recent article.

WorkersCompensation.com Features Dan Anders on MSP Policy Updates

The article reviews several important MSP and MSA developments. MSAs cost less than many stakeholders think, opioid allocations are down, and the PAID Act makes obtaining Medicare Advantage Plan data easier.

Key Medicare Secondary Payer and MSA Issues Reviewed

The article also notes that the Centers for Medicare & Medicaid Services said MSAs that are not approved by CMS could be viewed as “a potential attempt to shift financial burden” to Medicare.

Read the Full WorkersCompensation.com Article

The article, “MSA Policy Updates, Changes Likely in Store for 2022, Expert Predicts,” can be read here. Remember it’s just a one-time process of subscribing to this free section of Workerscompensation.com.

The DEA Finally Decides To Reschedule Hydrocodone

August 27, 2014

Last week the DEA released a final rule on the rescheduling of hydrocodone removing it from the schedule III controlled substances list in favor of a schedule II designation. To be clear, this decision specifically addresses hydrocodone combination products (i.e., hydrocodone-acetaminophen formulations such as Vicodin) as hydrocodone by itself has always been a schedule II drug.

The new parameters surrounding the prescribing of hydrocodone under the more restrictive schedule II classification will go into effect on October 6, but the decision by the DEA in conjunction with the Assistant Secretary for Health of the U.S. Department of Health and Human Services has been a long time coming. Hydrocodone combination products (HCP’s) have been schedule III since the Controlled Substances Act was passed in 1970 despite, as mentioned, the fact that hydrocodone itself has always been a schedule II drug. The thought initially was that by combining hydrocodone with another substance such as acetaminophen would diminish the abuse potential, but in the DEA’s final order they actually point to several different statistics that definitively portray just the opposite. Perhaps the most eye opening of these statistics tells us that high school aged children have actually abused Vicodin at twice the rate of Oxycontin, a more tightly controlled schedule II drug that has in the past, grabbed a lot more of the headlines.

Not surprisingly, there was a lot of pushback from the pharmaceutical community as well as some from the medical community throughout this process which has taken 15 years to come to fruition (the original petition was submitted by a physician in 1999). This dissent however, is misplaced and perhaps even irresponsible considering hydrocodone is the most prescribed drug in the United States. Last I checked, heart disease was the biggest killer in this country, not pain, yet hydrocodone is prescribed more than even ACE inhibitors (for hypertension) or statin drugs (to lower cholesterol). And if that is surprising to you try to wrap your head around this: the United States is comprised of about 4% of the world’s population yet we use 99% of the world’s hydrocodone.

The affect this will have on the workers compensation industry could prove to be significant. In terms of PBM’s who commonly push for mail order distribution, schedule II drugs have restrictive policies not conducive to this type of service. It would therefore be a good idea to check with your PBM to ensure that they are actively transitioning all applicable injured workers.

A second implication could be in regards to the widely utilized Official Disability Guidelines (ODG) which have long classified several HCP’s as Y drugs (recommended for first line treatment) within their workers compensation formulary. If changed to N drugs, those HCP’s would be subject to immediate utilization review in states such as Texas and Oklahoma that have instituted a closed formulary.

In my world of Medicare Secondary Payer compliance, it’s tough to say exactly where the effect of this rescheduling will be felt, but there are some trends that I hope we begin to see starting with less hydrocodone on MSA’s. It is easy to get caught up in cost drivers and how to mitigate unnecessary medical treatment in my line of work, and rightfully so when a prescription that was never meant to be maintained long term must be allocated for because it is part of the current treatment plan. But oftentimes, payers tend to overlook or not focus on HCP’s due to their relative low cost in comparison to some of their counterparts such as Oxycontin, Opana or Actiq. The result of that is we are consistently including long term use of hydrocodone-acetaminophen (for example) within MSA allocations in spite of the fact that no opioid has ever been recommended for long term use. This sort of tradeoff is unavoidable at times, but I will still hold out hope that the DEA’s most recent stance to reschedule hydrocodone combination products will prove to have a significant impact on the misuse and abuse of prescription painkillers, not just in our little world of work comp, but far reaching into our society as a whole.

How Will State Boards of Pharmacy Respond to Senate Committee’s Compounding Inquiry?

December 13, 2012

On November 19th, Chairman Tom Harkin (D-IA), Ranking Member Mike Enzi (R-WY) and members of the Senate Health, Education, Labor and Pensions Committee sent letters to all fifty state boards of pharmacy, the entities responsible for maintaining registries of pharmacies operating within their state. The HELP Committee is investigating the New England Compounding Center (NECC) for its production of tainted drugs that caused the recent outbreak of fungal meningitis, which has resulted in 33 deaths and more than 480 illnesses.

The letters were sent as a follow up to a hearing on November 15th in which Senators heard a very troubling account of NECC’s oversight record, which highlighted the gaps and grey areas that complicate the law establishing regulatory authority over such companies. In the course of the investigation, committee staff found that compounding pharmacies like NECC are required to register with their state of residence, and not with the U.S. Food and Drug Administration. This inquiry will help lawmakers to assess the scope of these companies nationwide. Today’s letters will also assist the committee as it determines what changes need to be made to ensure that compounded drugs are safe and available for patients and hospitals who need them.

“The outbreak raises serious questions about the level of oversight that a large-scale compounding pharmacy was subject to, both by state and federal regulators, and what if any additional steps need to be taken to prevent such a tragedy in the future. Therefore, as part of our investigation, we write to request information regarding general oversight of compounding pharmacies in your state and what actions you have taken to address this meningitis outbreak,” the Senators wrote.

Key Points Made in the Inquiry
As foundation for its request for information, HELP noted that the Centers for Disease Control and Prevention (CDCP) linked the recent meningitis outbreak to three lots of preservative-free methylprednisolone acetate produced by the New England Compounding Center (NECC) — a compounding pharmacy in Massachusetts. According to the CDCP, the three lots consisted of 17,676 products distributed to 23 states, exposing approximately 14,000 patients since May 21, 2012. As of November 16, 2012, at least 480 patients have become ill throughout the country, of which 33 have died as a result of the contamination.
In order to better understand how states address the potential issue of compounding pharmacies distributing large quantities of drugs throughout the country and whether additional federal oversight may be necessary, HELP requested that each state’s board of pharmacy provide information responsive to its requests as noted below:

Does your agency require compounding pharmacies to identify if they produce large volumes of drugs, if they compound sterile injectable products and/or ship their products across state lines? Do your inspection procedures vary based upon the production of sterile drugs, or large quantities of drugs, or drugs shipped across state lines?
Does your state require that pharmacies engaged in sterile compounding comply with USP and if so what is your procedure for ensuring compliance with the standard?Are compounding pharmacies in your state required to have a patient-specific prescription prior to producing a compounded drug or are they able to produce batches of products without a prescription?
Please provide the name and address of all pharmacies in your state that hold licenses or waivers or other exceptions that permit the pharmacy to operate in the absence of providing a full service retail pharmacy and meet all of the following three criteria (to the extent that you have information that allows you to identify pharmacies this way):
- engage in sterile compounding;
- hold licenses in other states; and
- engage in compounding as opposed to dispensing.

Assuming the states responded, information should have been available no later than Friday, December 7, 2012. Unfortunately, no responses have been published at this point, but it will be interesting to see how each state views its responsibilities to oversee compounding pharmacies at the state level.

Join Us In Vegas… Ask How Tower Triage Can Save Millions

October 29, 2012

Wednesday, Nov 7-9 Las Vegas Convention Center.

For 20 years, the National Workers’ Compensation and Disability Conference® & Expo has been the industry’s leading training event. And this year’s event is taking it to the next level – making it the best ever!

Key NWCD presentation tracks include the following:

A new full set of sessions will explore and deliver tangible, actionable solutions to the opioid crisis in workers compensation.
New ‘Regional Differences Sessions’ will each tackle the most challenging issues in a particular area of the country and provide you with practical strategies to overcome them.
New interactive ‘Think Tanks’ give attendees an opportunity to exchange innovative ideas with industry peers and leaders.
Enhanced legal track for attorneys and non-attorneys via partnership with LexisNexis.

Click here for more info on NWCD.

And for those who seek the latest in optimized settlement and Pre-MSA intervention strategies, stop by Booth #936 to learn more about the challenges of the current CMS review model and what Tower MSA Partners is doing to save clients millions.

Tower Triage enables employers and carriers to:

Mitigate CMS exposure
Optimize patient care
Expedite settlement

For more information , or to request a meeting with one of our executive team members, email us at info@towermsa.com.

Tower MSA Partners

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