Tower MSA Partners Archives

CMS to Provide RREs with Response File on ORM Record Changes

January 11, 2023

book marked by sticky notes illustrating changes Section 111 reporting on ORM

Starting July 2023, Responsible Reporting Entities (RREs) can access updates/changes that another source has made to their claims for Ongoing Responsibility for Medicals (ORM). The Centers for Medicare and Medicaid Services (CMS) announced this in an update to its MMSEA Section 111 NGHP User Guide, Version 7.0.

It may surprise insurers and self-insurers that the ORM data they report through Section 111 reporting can be modified by the Benefits Coordination and Recovery Center (BCRC), which coordinates benefits on behalf of CMS. For example, suppose a claimant contacts the BCRC and advises that they are being denied medical care due to an open ORM (ORM indicates the RRE accepts the claim). In that case, the BCRC may update the ORM record to indicate that medical has been terminated (especially if the claimant indicates the case has been settled).

The RRE needs to be notified of this action to correct its reporting or to advise the BCRC that this was an erroneous change to the record.

Presently, and in our experience, the BCRC typically issues a letter to the RRE advising of the change it made to the ORM status. Starting this summer, RREs can also access these changes through Section 111 reporting. The revised user guide states:

Effective July 2023, RREs will be able to opt in via the Section 111 secure website to receive a monthly NGHP Unsolicited Response File. This will provide critical information about updates to ORM records originally submitted in the last 12 months and allow RREs to either update their internal data or contact the Benefits Coordination & Recovery Center (BCRC) for a correction.

This report will provide the source of the record modification and the reason for it. This should eliminate confusion when the BCRC changes ORM reporting data.

Other Updates to Section 111 User Guide

CMS included these other updates in Version 7.0 of the user guide:

Sections 6.4.2, 6.4.3 and 6.4.4. of Chapter III: Policy Guidance indicated CMS would maintain the $750 reporting threshold for physical trauma-based liability insurance settlements and the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals.
In Chapter IV: Technical Information besides the aforementioned ability to, as of July 2023, obtain an NGHP Unsolicited Response File, CMS put in place the following changes:
Information on recovery agents was clarified to emphasize that such agents need written authorizations to pursue any post-demand actions (Section 6.3.1).
Recovery agents may now view the Open Debt Report on the Medicare Secondary Payer Recovery Portal (MSPRP), if the agent has an active MSPRP account with a TIN matching one submitted on the RRE’s TIN Reference File (Section 6.3.1.2).
ORM Termination Date field number 79 was corrected for the Event Table (Section 6.9.1).

As Tower is a recovery agent for many of our clients, the ability to download a copy of the Open Debt Report will be helpful in monitoring CMS’s ongoing recovery actions.

Finally, CMS updated Chapter V: Appendices as follows:
The CP13 soft edit policy limit amount has decreased from $1000 to $500 (Appendix F).
For the TIN Reference File, the Go Paperless Indicator is no longer required when submitting the Recovery Agent TIN (Field 25) (Appendix G).

If you have any questions on these updates, don’t hesitate to contact Tower’s Chief Compliance Officer, Dan Anders, at Daniel.anders@towermsa.com or 888.331.4941.

Happy Holidays From Your Friends at Tower MSA Partners

December 21, 2022

Alt: Holiday Greetings From Tower MSA Partners

We’ve had an exciting year of growth at Tower MSA Partners in 2022 and would like to extend our appreciation to you, our valued partners, who have supported us. Whether this is your first year as a Tower client, or one who has been with us for many years, Tower’s success results from your loyalty.

Our team works diligently each and every day to earn your trust by providing a service level unmatched in the MSP industry. And we can do that only through the expertise, knowledge, professionalism and commitment of our amazing staff, also unmatched in our industry. Together with our team, we hope we have met and exceeded your service expectations throughout the past year.

We extend our warmest wishes to you and yours. A Merry Christmas and Happy Holidays from your friends at Tower MSA Partners.

Tower Releases White Paper on Future Medicals in Liability Settlements

December 13, 2022

woman sitting in a dr waiting room to discuss her liability case

This past October, the Centers for Medicare and Medicaid Services (CMS) withdrew its proposed rule on future medicals in liability settlements from review by the White House Office of Information and Regulatory Affairs (OIRA). (See CMS Withdraws Proposed Rule on Future Medicals in Liability Settlements).

Right now, we don’t know if a proposed rule around Liability Medicare Set-Asides (LMSAs) will be reworked and resubmitted to OIRA for consideration soon or whether CMS is closing out regulations around liability settlements and future medicals for the foreseeable future.

Given the lack of guidance from CMS, we thought this was an opportune time to update our white paper, Navigating through the Fog: Medicare, Future Medicals & Liability Settlements. Authored by Tower’s Chief Compliance Officer Dan Anders, the paper explores CMS authority to regulate future medicals and provides guidance to the liability practitioner as to how to address future medicals at the time of settlement.

AASCIF Publishes Tower Article on MSA Submit vs. Non-Submit Debate

December 12, 2022

In its fall newsletter, the American Association of State Compensation Insurance Funds (AASCIF) published an article entitled “Despite the Controversy, MSA Submission is Still Okay.” Written by Tower’s Chief Compliance Officer, Dan Anders, the article details the pros and cons of Centers for Medicare and Medicaid Services (CMS) approval of an MSA.

As the article concludes, “While the submit vs. non-submit dispute will undoubtedly continue, the MSA approval process allows parties to obviate the risk of shifting future injury-related medical care to Medicare by obtaining a stamp of approval.” Recognizing that the submission process can sometimes increase settlement costs, the article provides tips on obtaining a quick CMS MSA approval and reducing cost drivers.

Post-Settlement Care, Cost and Compliance Through Professional Administration

December 6, 2022

Picture of Medicare billing statement for Section 111 WCMSA reporting.

While workers’ comp payers invest considerable resources to manage and settle claims, they don’t always prepare Medicare-eligible injured workers for life after settlement. These patients have usually been in the workers’ comp system for several years. And the system has paid for their injury’s treatment and medication, and in some cases, coordinated their care.

When their claim closes, all that comes to an end. Injured workers are on their own to navigate the healthcare system and handle the bills. They need to pay for doctors’ visits and medication from their Medicare Set-Asides (MSAs). They also need to make sure Medicare doesn’t have to pay for their injury-related care. Post-settlement compliance responsibilities can be overwhelming.

Tower’s recent Premier Webinar: Care, Cost & Compliance Through Professional Administration featured Nicole Chappelle who has nearly 30 years’ experience in all aspects of claims management — before and after settlement. Now Vice President of Settlement Solutions for Tower’s partner Ametros, Nicole joined our Chief Compliance Officer Dan Anders for what could be our liveliest webinar yet.

Here are some takeaways:

Injured workers who are also Medicare beneficiaries can self-administer their MSA or use professional administration.
The Centers for Medicare and Medicaid Services (CMS) highly recommends professional administration for beneficiaries who take opioids and other frequently abused controlled substances.
Professional administration is available for MSAs that are CMS-approved and for those that are not submitted for CMS approval.
Payers typically cover Ametros’ one-time professional administration fee of $1,000.

Although CMS allows beneficiaries to self-administer an MSA, it strongly recommends they consider professional administration. So do we.

First, MSA funds can only be used to pay for Medicare-covered medical treatment and prescription drugs related to the claim. Learning what Medicare does and doesn’t cover is challenging at best. It’s even more confusing for an injured worker whose workers’ comp program paid for items that Medicare does not cover, such as a sophisticated power wheelchair, home healthcare, and off-label use of certain medications. Will the typical, older injured worker understand this?

Additionally, MSA funds must be kept in an interest-bearing checking or savings account and used only for the aforementioned Medicare-covered care related to the claim. Even the interest needs to be used for this purpose.

The administrator has to maintain itemized medical and pharmacy receipts, bank statements, and other records for each transaction from the MSA account. An attestation of these expenditures needs to be submitted to the Benefits Coordination & Recovery Center (BCRC) every year.

If the MSA is funded with an annuity and funds run out in any given year, the administrator must report the temporary exhaustion of funds to the BCRC. Should funds be permanently exhausted, the administrator needs to send the BCRC a final attestation letter confirming the situation.

If MSA funds remain when the beneficiary dies, the executor or administrator is to notify the BCRC and pay for outstanding (related) medical bills from the fund. But would an executor know to do this?

Some things are best left to professionals.

If you’d like to see the whole webinar, please contact Dan Anders at daniel.anders@towermsa.com for the link and slides. He’s happy to connect you with Nicole Chappelle, too. And, as always, if you have any questions about MSAs, post-settlement compliance, or other Medicare Secondary compliance issues, get in touch with Dan.

Build a Better Tower: Partnerships Speed Settlements of Workers’ Comp Claims with Medicare Set-Asides (towermsa.com)

CMS Announces Upcoming Section 111 Webinar / WCMSA Reference Guide Update Released

November 15, 2022

Tower MSA Partners covers CMS new guide on Medicare conditional payment appeals and the upcoming Section 111 reporting webinar.

The Centers for Medicare and Medicaid Services (CMS) recently published a Section 111 reporting webinar notice and an update to its CMS WCMSA Reference Guide.

CMS Section 111 Reporting Webinar

CMS will hold a Section 111 NGHP Webinar on December 6, 2022, at 1:00 PM ET. The notice says:

CMS will be hosting a Section 111 NGHP webinar. The format will be opening remarks by CMS, a presentation that will include NGHP reporting best practices and reminders followed by a question and answer session. For questions regarding Section 111 reporting, prior to the webinar, please utilize the Section 111 Resource Mailbox PL110- 173SEC111-comments@cms.hhs.gov.

The webinar notice can be found here. We encourage anyone involved in the management of Section 111 reporting to tune into it. Please note that there is no pre-registration; instead, the link and call-in phone numbers are on the notice. You just log in shortly before the webinar’s start time.

WCMSA Reference Guide Update

The update to CMS’s WCMSA Reference Guide, Version 3.8 provides for changes to the re-review criteria. (Because CMS does not have a formal appeals process after an MSA determination, it allows what are called re-review submissions). Currently, CMS allows for re-reviews for mathematical errors and missing documentation. It has now added a section for submission errors which provides:

Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual. Note: This submission option is only available for approvals from September 1, 2022 forward.

Examples include, but may not be limited to: medical records with incorrect patient identifying information or rated ages where the rated-age assessor provided incorrect information in the rated-age document.

Rather than applying to submitter errors, this addition to the re-review policy appears to account for errors in the documentation that was provided to the submitter, such as a rated age or medical records.

Tower conducts a thorough review of all relevant documentation when the MSA is prepared and submitted. Consequently, documentation errors are identified and corrected before MSA submission. As such, we expect to make minimal use of the Submission Error Re-Review.

CMS also added a new section entitled Re-Review Limitations:

16.2 Re-Review Limitations

Note: The following re-review limitations are only available for approvals from September 1, 2022 forward.

Re-review shall be limited to no more than one request by type.

Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error.

Re-review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.

It appears that the long-time policy of unlimited re-reviews has come to an end. We understand CMS’s statement that a re-review “shall be limited to no more than one request by type” to mean one re-review is allowed for a mathematical error, one for missing documentation, and one for a submission error.

CMS’s intention for stating that a “disagreement surrounding the inclusion or exclusion of specific treatment or medications does not meet the definition of a mathematical error” is not clear. While perhaps not a math error, when medical records from a treating physician clearly say surgery is no longer recommended or medication has been discontinued but CMS includes such treatment or medication in the MSA, we submit it as an error.

Tower has submitted numerous re-review requests to remove or modify treatment or medication from the MSA based on treating physician statements in the medical records. Tower has a 68% success rate with re-reviews when CMS previously issued an MSA counter-higher, proof that these are reasonable requests. We hope the addition of Section 16.1 does not signal CMS’s intention to reject these reasonable re-review requests.

If you have any questions, please do not hesitate to contact Dan Anders, Tower’s Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

For the First Time, CMS Releases Key Metrics on WCMSA Review Program

November 9, 2022

Person pointing out metrics on a posterboard to measure Medicare Set Aside.

The Centers for Medicare and Medicaid Services (CMS) recently released data that provides insight into its Workers’ Compensation Medicare Set-Aside (WCMSA) reviews. This is the first time CMS has released such detailed metrics.

CMS shared statistics for a 3-year period of 2020 through 2022 (CMS’s fiscal year ends on Sept. 30). The data compared proposed MSA amounts with the CMS-recommended amounts (what we typically call the “approved” MSA amounts). The data can be found here.

MSA reviews are down

In 2020 CMS completed 16,517 reviews and by the FY end of 2022, this had dropped to 13,752 reviews, a 17% decline.

The reason for the decline is up for speculation. There may have been fewer settlements and thus fewer MSAs during the pandemic. However, NCCI’s data* show that claim frequency only declined by about 1% when 2020 and 2021 are considered together.

Another theory is that the reduction reflects a trend of settling parties choosing not to submit the MSA to CMS for approval. Whatever the reason, there has been less engagement with the CMS WCMSA review program.

Review Methodologies Remain Consistent

When CMS disagrees with a proposed MSA amount it issues a counter-higher with an amount it recommends for the MSA allocation. The data provided by CMS show that the variance between total MSAs proposed versus recommended change was 13% (2020), 15% (2021) and 14% (2022). This consistency of result is because CMS’s WCMSA review methodologies have remained largely the same over the last several years.

Average Recommended MSA Is Steady

The year-over-year data show very little change in the average recommended MSA amount from $84,563.33 in 2020 to $81,571.75 in 2022.

A Billion Dollars a Year

The CMS data show that the amount the agency consistently recommends for all the MSAs comes to over $1 billion annually. However, this does not necessarily represent $1 billion in savings to Medicare. Savings result when the MSA is funded in a settlement and the MSA funds are expended for injury-related medical care that Medicare would otherwise cover.

How Tower’s MSAs Stack Up

The release of these statistics gives us a unique opportunity to compare Tower CMS-approved MSAs against all CMS-approved MSAs.

Average CMS-Approved MSA (2021 numbers):

CMS: $80,741 Tower: $54,956

Tower’s CMS-approved MSAs are 32% lower than the CMS average approved MSA

And if we isolate just the prescription drug component of the MSA.

Average CMS-approved Rx Amount in MSA (2021 numbers):

CMS: $20,916 Tower: $14,079

Tower is 33% lower than the CMS average for the prescription drug component.

These comparisons prove that Tower’s MSA allocation methodology along with our focus on cost mitigation through interventions, such as our Physician Follow-up service, reduce MSA allocations. Simply put, what this means to our partner clients is millions of dollars in savings. These metrics also show that cost reductions can be obtained, even when payers choose the CMS MSA approval process.

The release of data on CMS programs has been a policy initiative of the National Medicare Secondary Payer Network (MSPN), to which Tower belongs. We are pleased that MSPN’s efforts have resulted in this release.

We also thank CMS for publishing these statistics. Hopefully, it will become an annual report that includes more metrics on WCMSA reviews, such as the percentage of MSA proposals that are developed for information post-submission. It would also be interesting to learn how many MSAs are funded in a lump sum versus those funded via an annuity. In addition, MSPN is interested in metrics surrounding Section 111 reporting and Medicare conditional payments.

If you have any questions about this report or anything else on MSP compliance or MSAs, please feel free to contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

*See Rabb, W., (2022, May 11). “Claims Frequency Up for 2021, but Workers’ Comp Profitability ‘Unprecedented,’” Insurance Journal.

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.