2 New Tricks for New Workers’ Comp Claims

Published originally on February 6, 2017 on WorkComp Wire

 

As discussed in last week’s article, old dogs can be taught new tricks. A proactive settlement initiative can not only get legacy claims off the books, but it can also dramatically reduce costs and improve patient care. In one case, a man who suffered a minor back injury at work more than 25 years ago was weaned off fentanyl, hydrocodone, and several other drugs. The claim’s pharmacy spend went from $1,200 to $600 a month and a settlement is planned.

 

An employer that inherited legacy claims in an acquisition initiated an aggressive settlement program that produced $6.5 million savings on 43 MSAs during a 10-month period.

 

Yes, the settlement initiatives produce excellent outcomes for old dog claims. But the lesson here is that these so-called new tricks are available throughout claims handling. Adopting a settlement mindset from day-one can prevent claims from spiraling out of control and becoming old dogs. Think of the medical and indemnity cost savings as well as litigation costs that can be saved as a result of settling these claims short of attorney referral.

 

Remember these two new tricks:

 

  • Proper medical documentation of a file results in better claims handling. If medical treatment records are missing from the file, prescription history is absent or inconsistent with the medical records, or medical care is left open ended, it is difficult to assess the appropriateness of ongoing and future medical care.
  • Pharmaceutical intervention does not need to wait. A claim must be consistently evaluated for the appropriateness of recommended and ongoing prescription medication use. The addition of opioids weeks into the claim is a red flag. Do not wait until on the brink of settlement negotiations to intervene on prescription medications use, do it now.

 

Clinical and legal partners must drive a successful outcome for employer and employee. Every stakeholder (nurse case manager, adjuster, pharmacy benefit manager, defense attorney, or physician) should watch for red flags and intervene themselves or relay issues to the claims handler to determine the necessary action plan to right the ship before the claim gets more difficult to control.

 

When pursuing a settlement initiative involving complex, “old-dog” claims, savvy payers price out future medical exposure, identify cost drivers, and decide which claims to settle right away and which warrant intervention. The smart payers also learn from these old dog claims and put best practices in place to address cost drivers early on in claims handling. What is the impact of pursuing such a claim strategy? Here are the results from an employer who converted an old-dog settlement initiative into a standard for new claims handling:

 

  • 29% reduction in open claims after one-year
  • 43% reduction in open claim after three years
  • 14% reduction in total costs after one-year
  • 26% reduction in total costs after three years
  • 40% reduction in attorney referrals after three years
  • 25% reduction in pharmacy costs after three years
  • 55% reduction in CMS-approved MSA amounts after three years

 

It’s never too early or too late for clinical intervention on a claim with the purpose of driving a successful resolution to the claim. While old dogs can be taught new tricks, the best strategy is to incorporate settlement initiative protocols into claims handling best practices.

 

 

About Dan Anders

 

Daniel M. Anders, Esq., MSCC is the Chief Compliance Officer for Tower MSA Partners. A certified Medicare Set-Aside Consultant and attorney, he oversees the Medicare Secondary Payer (MSP) compliance program. Mr. Anders is responsible for ensuring the integrity and quality of the MSA program and other services and products and he provides education and consultation to Tower MSA clients on all aspects of MSP compliance.

 

Mr. Anders is the former Senior Vice-President of MSP Compliance for ExamWorks Clinical Solutions and he has extensive litigation experience from his prior position with the Chicago law firm of Wiedner & McAuliffe. He holds a Juris Doctor from Chicago-Kent College of Law and a Bachelor of Arts degree from Loyola University Chicago.

 

Contact Mr. Anders at 847.946.2880 or daniel.anders@towermsa.com

 

 

About Tower MSA Partners
Tower MSATower MSA Partners is a national provider of Medicare Secondary Payer services, including Section 111 Reporting and Conditional Payments along with Medicare Set-Aside preparation, submission and oversight. Its proprietary MSP Automation Technology Suite drives MSP compliance best practices and provides end-to-end visibility into each activity. Tower’s other services include pre-MSA Triage, physician peer reviews, MSA administration, medical cost projections, and life care plans. With more than 50 years combined experience in pharmacy, legal oversight and medical care, Tower proactively stages claims and works collaboratively with clients to identify issues and intervene to modify outcomes. Tower remains involved in the claims, through final resolution, MSA and/or other settlement. This model enables Tower’s clients to provide better care to injured workers, reduce claim and MSA costs, and obtain CMS acceptance of the MSA. For more information, visit www.towermsa.com and subscribe to Tower’s www.mspcomplianceblog.com.

How Old Dog Workers Comp Claims Can Learn New Tricks

Published originally on January 30, 2017 – WorkCompWire

 

By Dan Anders, Chief Compliance Officer, Tower MSA Partners

 

Dan AndersThe saying goes you can’t teach old dogs new tricks. But when it comes to clinically driven settlement initiatives involving complex “old dog” workers’ compensation claims, old dogs can be taught new tricks. What’s more, the lessons learned from old dog claims can become a foundation for “new tricks” that can be applied in the management of all claims, building a best practices model that stops the cycle.

 

“Old dog” claims refer to legacy claims or claims which have been open for some time and continue to draw down on the indemnity and medical reserves as a result of ongoing time off work and/or continued medical care. Old dog claims can come from a merger or acquisition, especially if the companies have different claims management and settlement philosophies. Complex claims that were once in front of an adjuster on a regular basis may also become old dogs when shunted aside by an influx of new claims.

 

Whether triggered by a merger, a change in management or the sheer volume of legacy claims, an aggressive settlement initiative can push many old dog claims to closure, and if not closure, there is clear communication that changes will occur. Whether through settlement or a change in treatment, the “old dog” will learn “new tricks.”

 

Successful settlement initiatives involve multiple partners, first to identify and analyze cost drivers across a large number of old open claims, then match them with appropriate interventions (file review, physician peer review, clinical oversight, legal action) to resolve all issues blocking settlement. Once the obstacles are addressed, the next step is to work with the settlement partner to create an incentive for both injured worker and payer. If settlement can be achieved, it is a win, win for all stakeholders. If settlement isn’t possible, injured workers and their physicians are challenged within the context of jurisdictionally approved treatment guidelines to improve care.

 

If executed consistently as part of a strategic plan to identify, intervene and remain involved until closure, the lessons learned from this type of settlement initiative will become imbedded into the claims management culture of the payer.

 

 

Identifying and Analyzing Claim Cost Drivers
Consider the case of an employer with longstanding open medical and legacy claims. Some of these claims may involve injured employees who are actively treating, even if it is just maintaining medications, while others may involve patients whose current medical condition is unknown. In either case, the employer’s first step is a file review that identifies claims in need of addressing for case settlement. The next step is the employer involving a strategic clinical partner to properly assess ongoing and future medical exposure, if any.

 

The best methods for analyzing future medical exposure are through a medical cost projection or a Medicare Set-Aside (MSA) if the claimant is a Medicare beneficiary or close to becoming one. An MSA has the added benefit of limiting medical care to treatment and medications that are Medicare-covered, thus potentially reducing future medical exposure for settlement. The goal of either method is to identify any red flags, such as:

 

  • Use of opioids, muscle relaxants and NSAIDS
  • Multiple prescribers of medications
  • Open-ended recommendations for surgery
  • Spinal cord stimulator recommendation
  • Prescription history that is inconsistent with the medical records
  • Most recent treatment date is so old that it leaves medical care open ended
  • Indication outside of medical records that injured employee continues to treat, but not through the workers’ compensation claim

 

The clinical partner needs to understand how the legal aspects of a claim (denied body parts and conditions and legal determinations) impact the assessment of future medical care and to be able to work effectively with defense counsel to limit ongoing and future medical care. Once the clinical partner projects future medical care and identifies red flags, the partner and employer should separate the claims into those that can immediately move to settlement negotiation, those that could settle after clinical or legal intervention, and those that are unlikely to benefit from intervention and thus cannot settle.

 

 

Appropriate Clinical Interventions
One size does not fit all when it comes to the right intervention to impact the medical care on a claim. If old medical records indicate open-ended medical care, then the intervention plan may involve the clinical partner contacting the last treating physician to confirm there has been no medical care delivered since the last date of service. If there has been medical care, the partner may track down additional medical records and assess future medical care based upon those records.

 

If there is a significant medication spend, a physician peer review may be the most appropriate claim intervention. A physician peer review is conducted by a practicing physician who performs an in-depth analysis of an injured employee’s medication regimen, comparing it to evidence-based medical and pharmaceutical guidelines. The physician peer reviewer then contacts the treating physician and discusses the drug regimen and current guidelines and asks the treating physician to change the pharmacy treatment or the medical treatment plan. The clinical partner obtains the treating physician’s written agreement to change the course of medical treatment and drug regimen. The partner follows up with the physician to ensure that changes actually occur and secures copies of medical records documenting the changes prior to preparing a settlement document.

 

 

Claim Closure
Once changes to medical and pharmaceutical care take place, the clinical partner works with the employer or carrier to revise the initial projections of future medical care whether contained in a medical cost projection or an MSA. If the latter, the MSA should be submitted to the Centers for Medicare and Medicaid Services (CMS) for approval. A settlement team should be assembled to work with the adjuster or a manager to complete negotiations and finalize the settlement.

 

 

About Dan Anders
Daniel M. Anders, Esq., MSCC is the Chief Compliance Officer for Tower MSA Partners. A certified Medicare Set-Aside Consultant and attorney, he oversees the Medicare Secondary Payer (MSP) compliance program. Mr. Anders is responsible for ensuring the integrity and quality of the MSA program and other services and products and he provides education and consultation to Tower MSA clients on all aspects of MSP compliance.

 

Mr. Anders is the former Senior Vice-President of MSP Compliance for ExamWorks Clinical Solutions and he has extensive litigation experience from his prior position with the Chicago law firm of Wiedner & McAuliffe. He holds a Juris Doctor from Chicago-Kent College of Law and a Bachelor of Arts degree from Loyola University Chicago.

 

Contact Mr. Anders at 847.946.2880 or daniel.anders@towermsa.com

 

 

About Tower MSA Partners
Tower MSATower MSA Partners is a national provider of Medicare Secondary Payer services, including Section 111 Reporting and Conditional Payments along with Medicare Set-Aside preparation, submission and oversight. Its proprietary MSP Automation Technology Suite drives MSP compliance best practices and provides end-to-end visibility into each activity. Tower’s other services include pre-MSA Triage, physician peer reviews, MSA administration, medical cost projections, and life care plans. With more than 50 years combined experience in pharmacy, legal oversight and medical care, Tower proactively stages claims and works collaboratively with clients to identify issues and intervene to modify outcomes. Tower remains involved in the claims, through final resolution, MSA and/or other settlement. This model enables Tower’s clients to provide better care to injured workers, reduce claim and MSA costs, and obtain CMS acceptance of the MSA. For more information, visit www.towermsa.com and subscribe to Tower’s www.mspcomplianceblog.com.

CMS MSA Review Expansion to Liability Planned for 2018

We are not even a week into 2017, but already have news to share regarding Medicare’s planned expansion of its Workers’ Compensation MSA review process to liability in 2018. In its recently released Request for Proposal for the Workers Compensation Review Contractor (WCRC), the Centers for Medicare and Medicaid Services (CMS) includes an option allowing CMS to expand the responsibilities of the WCRC to review of Liability Medicare Set-Asides (LMSAs) and No-Fault Medicare Set-Asides (NFMSAs) effective July 1, 2018.

 

The CMS WCRC RFP Solicitation may be viewed here.

 

 

Background on CMS Review of MSAs

 

Since 2001 CMS has had in place an official voluntary review process for Worker’ Compensation Medicare Set-Asides (WCMSAs). A WCMSA, as CMS states, is a “financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury.” The purpose of the review then is “to independently price the future Medicare-covered medical services costs related to the WC injury, illness, and/or disease and to price the future Medicare covered prescription drug expenses related to the WC injury, illness and/or disease thereby taking Medicare’s payment interests appropriately into account.”

 

These WCMSA reviews were initially handled by the CMS Regional Offices spread throughout the country, but eventually transitioned to a centralized WCRC in 2005 (The CMS Regional Offices must still approve the review recommendation of the WCRC before it is released to the WCMSA submitter). CMS’s RFP solicitation for the new WCRC contract indicates the contract is to be awarded by June 30, 2017 with a contract term running for five years from July 1, 2017 to June 30, 2022.

 

 

Expectations for Liability MSA Reviews

 

Presently, CMS allows its 10 Regional Offices to accept voluntary requests for review of LMSAs at each office’s discretion. Some Regional Offices have consistently refused to review any LMSAs while other offices agree to review based upon criteria that seemingly changes over time and bears no indication that it is indeed the official policy of CMS. It appears then that just as it did in 2005 when CMS took the responsibility away from the Regional Offices for reviewing WCMSAs, CMS is now considering centralizing the process of reviewing LMSAs with a contractor, leaving the Regional Offices to only approve of the contractor’s recommendations.

 

Some may recall CMS launched a prior initiative to establish a formal policy for consideration of future medicals in liability settlements when it issued an Advanced Notice of Proposed Rulemaking in 2012. This initial effort was ultimately withdrawn by CMS in 2014. CMS’s new initiative began with this June 9, 2016 notice on the CMS website:

 

The Centers for Medicare and Medicaid Services (CMS) 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. Please continue to monitor CMS.gov for additional updates.

 

No town hall meetings were scheduled in 2016, however, based upon this RFP indicating LMSA reviews will not begin until at least July 1, 2018, CMS has given itself 18 months to develop and implement a formal LMSA review policy. In terms of how many liability settlements such a review process would impact, CMS seems uncertain. A Statement of Work attached to the RFP indicates “reviews could represent as much as 11,000 additional cases (based on all FY2015 NGHP demands), or as little as 800 additional cases annually, depending upon industry response.”

 

 

Tower MSA Takeaways

 

Over the past 15 years, starting with the formalized review of WCMSAs, continuing with the implementation of Section 111 Mandatory Insurer Reporting and recent stepped up efforts at denying injury-related medical care and recovery of conditional payments for medical care related to workers’ compensation, liability and no-fault claims, CMS has expanded its enforcement under the Medicare Secondary Payer Act. It is not surprising then that CMS’s next objective is formalizing a voluntary review process for LMSAs.

 

It has been our experience that when CMS does implement new policy and procedures it does take a deliberative approach evidenced by the at least 18-month timeframe signaled with this RFP to expand the MSA review process to liability and no-fault. Our expectation then is over the next 18 months or longer, CMS will provide additional announcements concerning the rules and procedures around expansion of the review process.

 

Tower MSA will be involved in these discussions and will keep you abreast of relevant developments. In the interim, there remain important obligations of parties to liability settlements and no-fault claims under the Medicare Secondary Payer Act. Rest assured that you can rely upon Tower MSA’s team of MSP compliance experts for consultation and expert guidance in liability and no-fault matters.

 

 

 

Author Dan Anders, Chief Compliance Officer, Tower MSA Partners. Dan oversees the Medicare Secondary Payer (MSP) compliance program. In this position, he is responsible for ensuring the integrity and quality of the MSA program and other MSP compliance services and products. Based upon his more than a decade of experience in working with employers, insurers, TPAs, attorneys and claimants, Dan provides education and consultation to Tower MSA clients on all aspects of MSP compliance. Contact: (847) 946-2880 or daniel.anders@towermsa.com

Christmas Miracles Can Happen in Workers’ Compensation

For those of us who deal with MSAs, it’s all too common to see claims at settlement time that started out as basic and simple, then spiraled downward as a result of bad prescribing habits, increased drug use and opioid addiction.  We hope for a different ending, but can  miracles really happen?

 

 

Background

 

In late 2015, Tower completed a pharmacy project for a small employer in California.  In the course of the project, drug triggers were identified, physicians were contacted and claimants were challenged to settle or make changes in treatment.  As you might imagine, many of the physicians fought the request for change.  But through perseverance, and working in tandem with the client, we pushed forward.

 

 

The Story as Shared by our Client

 

Dear Hany,

 

A few weeks ago, I was looking over the  case for one of the California claimants and wanted to share the amazing results we have achieved with this gentleman.

 

This case involved a 26 year old man at time of injury. He sustained a minor back injury but was taking Hydrocodone, Testosterone, Celecoxib, Lyrica, Nortriptyline, Methocarbamol, and FENTANYL.  With the recommendations and assistance from the Tower MSA Partners team, as well as support from his wife, we were able to get him into a new treating physician who agreed with our goal. He was weaned off of the Fentanyl, Methocarbamol, testosterone, hydrocodone, and Celecoxib. He has even started an exercise program.  He is now both proud and happy to report how well he is doing.

 

The injured worker is now 51 years old and he sadly notes that he missed out on 25 years of his life and his children’s lives because he was so “drugged”.   On a positive note, however, his new treating physician has been wonderful to work with and we see only good things for this claimant.

 

On the financial side we have now realized a reduction in the monthly Rx spend from $1,200 per month down to $600.  The injured worker is now only taking Nortriptyline, Lyrica and Celebrex and we expect to reduce reserves next year and approach him for a settlement in June, 2018.  None of this would have been possible if not for the Rx project and your team’s expertise, guidance and follow up assistance.

 

While we have had great success with many of the claims that we partnered on, this particular claim was really about improving his quality of life.  So please share my THANK YOU and gratitude with your team. Let them know that what they do can save a life and that is priceless.

 

 

It’s True….Miracles Can Happen in Workers’ Compensation

 

What a wonderful way to end the day and begin our holiday celebrations!

 

From all of us at Tower MSA Partners, our best wishes for a wonderful holiday, and a safe and prosperous 2017!

 

 

 

Author Rita Wilson, CEO, Tower MSA Partners, LLC. Rita oversees all business development, sales, marketing and operational activities, IT systems development, and identifies new product offerings in support of Medicare Secondary Payer Compliance. Prior to co-launching Tower MSA Partners in 2011, she founded and ran Select MRI, LLC, a diagnostic company, and Speedy Re-employment and Medicare Set Asides, an MSP compliance company. Previously, Wilson built out the operational and technology model for another startup, DirectCompRx, Inc., a subsidiary of Fiserv, Inc., ultimately becoming its CEO. Wilson is a Board Member for the National Association of Medicare Set Aside Professionals (NAMSAP). http://towermsa.com

Use Non-Therapeutic Pharmacy Changes to Reduce Your MSA Costs

Prescription drug costs represent both a source of national attention and a major cost driver of workers’ compensation claims dollars.  This trend will only continue.  Failure to use creative ideas to reduce the pharmacy portion of a claim can impact the bottom line and efficiency of your program.  One such creative solution all claims management teams should seek is service providers that identify non-therapeutic pharmacy changes that can yield significant MSA savings.  This is especially the case when your claim has a long tail medical treatment plan and includes a Medicare Set-aside.

 

 

Pharmacy Costs and Work Comp

 

A September 2016 NCCI research brief states “for every $100 paid for medical services provided to workers injured…$17 will be paid for prescription drugs.” They continue to state…”the prescription drugs portion of medical costs increases rapidly as claims age. For every $100 of medical services paid on claims older than 10 years, approximately $45 to $50 will be for prescription drugs.”

 

 

Non-Therapeutic Pharmacy Changes

 

The rapid increase in the prescription drug portion of medical costs in aging claims makes review of the pharmacy treatment plan compounded in importance when creating a Medicare Set-Aside for future medical costs.

 

Non-therapeutic pharmacy changes include:

 

  • Switching treatment from a brand name drug to generic.
  • Confirming discontinuation of a prescribed drug when the medical records are ambiguous
  • Requesting that the physician consider moving from a prescribed drug to over-the-counter.

 

 

Medicare Set-asides: Case Study – $774,583 Savings

 

Step 1: MSA Triage

 

  • Injury:
    • Struck by Lighting: Electric shock, difficulty sleeping, pain, depression, seizure activity

 

  • Prescription & Treatment Plan
    • hydrocodone/apap, baclofen, Topamax, duloxetine, Keppra, naproxen, and clonazapem, sleep apnea equipment

 

  • Original Projected MSA Cost 
    • $1,416,513 with brand new drugs and sleep apnea equipment

 

 
Step 2: Identify & Execute Intervention Strategy

 

  • Original Projected MSA Cost
    • $1,416,513 with brand new drugs and sleep apnea equipment

 

  • Non-Therapeutic Physician Follow Up Strategy
    • Identified opportunity to switch to generic, facilitated communication with physician, employee, and attorney to execute switch

 

  • Savings Realized
    • Future medical reduced from $1.4m to $641,930 by substituting generic; accepted by CMS and saved $774,583.*


*case study provided by Tower MSA Partners

 

The main driver in this MSA allocation was the cost of the brand name prescription drugs Topamax and Keppra.  In the above example, the MSA provider identified the opportunity for savings, facilitated the successful switch to generic drugs among all stakeholders and obtained the written evidence of the change in treatment necessary to secure CMS approval. The result was a $774,583 MSA savings that was accepted by CMS. It is important to note that communication and coordination among all parties allowed the switch to occur and the savings to be realized.

 

 

 

Review Non-Therapeutic Pharmacy Changes – Fees

 

The opportunity to realize dramatic savings without altering the clinical outcome for the patient warrants that non-therapeutic physician changes should be reviewed as a standard part of every MSA case file.

 

When evaluating your MSA vendor, ask the question if this service is included in the standard fee, or if it’s an additional charge? A vendor that provides the service at an additional charge will not utilize it as often and will realize significantly less savings than one in which it’s included in the standard fee.

 

 

Conclusions

 

Medical treatment and prescription drugs will continue to be a driver in the cost of all workers’ compensation claims.  Alterations in prescriptions via non-therapeutic pharmacy changes can mean savings for the parties, as well as other benefits in workers’ compensation claims. Opportunities for these changes should be reviewed on every MSA case file.

 

 

 

For additional information on workers’ compensation cost containment best practices, register as a guest for our next live stream training.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

Using Evidence Based Medicine In The MSA Review Process

RitaWilson

Rita Wilson, CEO, Tower MSA Partners

Rita Wilson, CEO, Tower MSA Partners

… on using evidence based medicine in the MSA review process

 

While CMS includes evidenced based medicine in its MSA evaluation resources, it does not require treatment to line up with science in order to be approved and allocated.  Consequently, many MSAs allocate for inappropriate medical procedures and pharmacy regimens that threaten patient safety.

 

Claims should be staged to identify treatment issues and cost drivers prior to preparing an MSA.  A proper pre-MSA Triage compares six months of medical records to clinical guidelines and this process frequently identifies recommended procedures or surgeries that have not occurred – and may never be needed.  To avoid funding procedures that will never take place, the next step is to contact treating physicians to clarify recommendations and make sure the medical records reflect ensuing changes.

 

Triage should also detect inappropriate pharmacy regimens that pose risks to patient safety and drive up settlement costs.  Often, injured employees are taking opioids, benzodiazepines and other drugs deemed inappropriate for their conditions by evidence-based guidelines.  Off-label use of certain drugs, like Lyrica, is another issue because Medicare will not pay for off-label use of certain drugs.  Sometimes there are prescriptions that have never been filled.  If not addressed, CMS will require their costs to be allocated in the MSA.  A best practice MSA provider will work with treating physicians to discontinue inappropriate medications, monitor tapering and secure the documentation CMS requires to allocate for the updated pharmacy program.

 

Applying EBM to claims is an extra step in the settlement, but well worth the time.  It protects patient safety by making sure treatment is sound and reduces costs by removing drugs and procedures that fall outside science.  It’s the right thing for the patient and the payer.

 

 


Using Evidence Based Medicine In The MSA Review Process

 

The concept of future medicals and Medicare Secondary Payer compliance is a challenging component of any workers’ compensation claim management team seeking to reduce costs in an ethical manner.  The voluntary Medicare Set-aside review process established by the Centers for Medicare and Medicaid Services (CMS) compounds this problem.  Use of Evidence Based Medicine (EBM) is one method that concerned parties can use to challenge CMS polices and provide a consistent result that meets the needs of workers’ compensation programs.

 

 

Understanding the Voluntary MSA Review Process

 

CMS started to provide guidance to parties regarding the workers’ compensation Medicare Set-aside review process in 2001.  This took the form of policy memoranda that was sometimes contradictory and confusing.  In an effort to streamline the process and make it more understandable, CMS changed course and consolidated this information into the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide.

 

CMS will review a proposed WCMSA amount when the following workload review thresholds are met:

 

  • The claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or

 

  • The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00.

 

Consistent with federal regulation interpreting the Medicare Secondary Payer Act, CMS cautions parties that they must still consider Medicare’s interests even if a settlement does not meet the specified voluntary workload review thresholds.

 

 

Understanding CMS Policy Concerning Future Medicals

 

CMS does consider every workers’ compensation case in a proverbial vacuum.  For instance, “counter-highers” concerning the MSA allocation often arise in the following situations that most interested stakeholders consider unreasonable:

 

  • Degenerative changes that naturally occur resulting in prolonged medical care and treatment for a work injury that arguably only aggravates, but does not accelerate the an underlying condition. This prolonged care CMS seeks reimbursement for is often the result of the natural aging processes or prior non-work related injuries that sometimes require surgical intervention and costly prescription drug use;

 

  • The ongoing and sometimes excessive use of prescription pain medications. This is especially the case when it comes to opioid-based prescription medications, which significantly spike the cost of workers’ compensation claims.  These prescription medications can only be effective when used for acute pain relief and not long-term maintenance care; and

 

  • Issues raised in independent medical examination reports regarding the reasonableness and necessity of future medical care and treatment. Although these reports are prepared at the request of the employer/insurer, doctors performing these examinations have adequate foundation for issuing their expert opinions within a reasonable degree of medical certainty in a legal or administrative hearing.  CMS policy does not recognize the validity of these reports in the WCMSA review/approval process.

 

 

Using Evidence Based Medicine to Counter CMS Objections

 

EBM is a recognized approach within the practice of medicine that seeks to optimize the results in patient care via medical evidence based on research and design.  In the case of questions concerning the use of opioid-based prescription medications, this process is used to demonstrate the effectiveness of a certain treatment regimen and denote when the continued use losses it benefits.

 

Using EBM to stage the claim for submission and approval by CMS in the Medicare set-aside process does require work, but the payoff is significant.  The process includes utilization of medical records, scientifically supported medical research and an evaluation of trends to demonstrate the best course of future action for an injured worker in an effort to modify treatment.  It also includes a review of possible treatment modalities that discourage prescription drug abuse and deliver savings the interested stakeholders and an acceptable level of care to the injured party.  The use of medical experts to challenge inappropriate treatment, and the process of maintaining oversight over the claim until the CMS accepted evidence is obtained to demonstrate drug regimen can be time consuming, but the result is long-term savings and a CMS approved MSA that concurs with EBM guidance.

 

 

Conclusions

 

The challenges of the workers’ compensation system require members of the claim management team to be proactive.  One area includes the use of EBM to challenge CMS orthodoxy when it comes to costly future medical projections, which often include excessive use of dangerous opioid-based prescription drugs.  While costly, the use of EBM can reduce the threat posed by legacy claims.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Changing Hearts and Minds to Win the Battle Against Prescription Drug Abuse

The expansion of Medicare to include a prescription drug benefit has had varied results on the workers’ compensation system and compliance with the Medicare Secondary Payer Act.  While this expansion has assisted countless Medicare beneficiaries receive their necessary prescription drugs as an affordable price, it has come at a cost.  This is a setback in compounding the prescription drug epidemic and increasing the “cost” of a Medicare Set-aside allocation.

 

 

Prescription Drug Expansion in Medicare

 

The creation of the Medicare program in July 1965 allowed disabled and older Americans to receive affordable health care coverage.  While this was heralded as a step forward, the program lacked the ability of Medicare beneficiaries to receive an affordable prescription drug benefit.  Congress addressed this issue in 2006, when they expanded the Medicare program to include a Part D prescription drug benefit.  Under this new program, anyone who has coverage under Medicare Parts A or B (Traditional Medicare) is eligible for Part D.  This includes those receiving coverage under a Medicare Advantage Plan, which typically have Part D coverage as part of the plan.

 

Following the passages of the Part D program, CMS was quick to provide guidance on how Medicare Set-aside allocations should address this matter.  The result was a dramatic increase in the cost of such allocations given the increasing use of prescription drugs in injury treatment regimens.  Significant costs can also be incurred if the injured employee is using opioid-based prescription drugs.

 

 

Medicare Part D Adding to the Drug Epidemic

 

Prescription drugs abuse is dramatically increasing the cost of workers’ compensation claims.  An example of this impact is as follows:

 

  • $13,000: Average cost of a claim without opioids;
  • $39,000: Average cost of a claim with Percocet; and
  • $117,000: Average cost of a claim with long-acting OxyContin.

 

Under Part D guidelines, plan sponsors may in fact be fueling the prescription drug epidemic.  According to industry sources, it has been recommended that sponsors of Part D plans change dispensing guidelines in their plans for beneficiaries taking a 120 mg morphine equivalent daily dose.  This includes those beneficiaries who are using prescriptions for opioid-based prescriptions for more than 90 days.  Other factors that are leading to deadly results include people who are receiving their prescription medications from multiple prescribers and pharmacies.  The prolonged use of these prescription medications is not only expensive, but can result in addiction and negative health consequences.

 

In highlighting this problem, the National Alliance of Medicare Set-Aside Professionals (NAMAP) have become more engaged in educating stakeholders and advocating for change.  According to a recent statement from NAMSAP asked, “why do workers’ compensation MSA approvals often include future prescription allocations with Morphine Equivalent Dosages in excess of 120, 200, or even 500 per day, over the beneficiary’s full life expectancy?  And what message does a workers’ compensation MSA supporting these high opioid dosages over a patient’s entire life expectancy send to the addicted patient?”

 

 

Combatting the Epidemic: Being an Advocate for Change

 

No single law or rule that will end the opioid-based prescription drug problem in America and reduce workers’ compensation program costs.  Action instead must come from a demand for change in how we address the use of these prescription drugs within the system—to change the hearts and minds of policymakers.  It includes advocacy with the state and federal governments in how they view this matter when it comes to providing medical care and treatment to injured persons.

 

One important action comes in the form of allocations for opioid-based prescription medications in Medicare Set-aside allocations.  Under the current CMS rationale, medical care and treatment, including pharmacy related issues, must cover the life expectancy of the claimant.  This philosophy is not practical for a claimant using OxyContin or other related prescriptions.  By using Evidence Based Medicine (EBM) techniques, interested stakeholders must highlight the dangers of long-term opioid-based drug use and instead, promote their use for shorter periods.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Selecting the Right MSP Compliance Service Provider

Selecting the right Medicare Secondary Payer (MSP) compliance service provider is an important part of any claims operation.  These service providers are essential when it comes to making sure a claim complies with all aspects of the Medicare Secondary Payer Act by providing suggestions to help resolve troublesome cases.  This must include a focus on selecting someone who provides innovative solutions to complex problems.

 

 

Understanding the Medicare Secondary Payer Act

 

The Medicare Secondary Payer Act was passed into law in 1980, but was largely ignored until the late 1990s.  Since that time, claim management teams have paid considerable attention to compliance with the Act by considering Medicare’s interests in all workers’ compensation claims.

 

One part of MSP compliance is the projection of future medicals related to injury-related claims.  This includes the careful review of medical records related to the injury and projecting costs associated with future medical care reimbursable by Medicare.  The result should be a medical cost projection that is reasonable.  Another factor is an acceptable approval rate for those allocations submitted for review and approval under the voluntary workers’ compensation Medicare Set-aside submission process.

 

 

Threshold Factors for Consideration

 

There are several threshold factors for consideration when selecting a MSP compliance service provider.  When making this decision, it is important to answer the following:

 

  • How would you describe your current MSP compliance program for workers’ compensation?

 

  • What is the MSP compliance provider’s experience and expertise including legal/compliance, and pharmaceutical/medical?

 

  • How are clinical interventions handled? Is the process seamless?

 

  • What is your criteria for success? (or how do you measure success?)

 

  • What is the level of communication your current MSP partner provides during the Medicare-related processes?

 

By answering these questions, the leadership within a claims management team will understand the importance of a provider that offers innovative services.

 

 

Moving Beyond the Basics of MSP Compliance

 

Countless MSP service providers do an excellent job providing precise medical allocations.  While this is an important component of effective compliance efforts, it is important to seek a provider who is able to offer innovative services that take the extra steep.

 

  • A sophisticated service provider utilizes technology that drives all compliance related processes.  This includes the ability to manage in an effective manner the three main components related to the MSP Act: conditional payment resolution; Medicare Set-asides; and Section 111 Mandatory Insurer Reporting.

 

  • Pre-MSA Triage. Stopping problems before they occur is an important component missing in most MSP compliance programs.  When selecting the right service provider, it is essential to work with a provider that can identify barriers to settlement and provide specific intervention recommendations.  This should include physician peer review, drug utilization review and clinical oversight.

 

  • Compliance automation and tracking services. Automation allows interested members of the claim management team to track Medicare related activity on a claim from the time a beneficiary is identified through final settlement via end-to-end visibility.  It also allows team members to view in real-time what actions the MSP service provider is taking and what additional steps will occur in the future.  This includes communication with physicians, pharmacists, conditional payment searches, and medical/pharmaceutical interventions.  This not only give claim handlers peace of mind, but also frees them to address issues that require attention.

 

Conclusions

 

Effective MSP compliance includes a service provider that goes beyond the basics.  These providers will offer services that allow members of the claim management team to focus on their job and provide information and resources to comply with Medicare regulations in workers’ compensation claims.

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Reducing Future Medicals through Medicare Secondary Payer Automation

RitaWilson

Rita Wilson, CEO, Tower MSA

…on reducing future medicals through Medicare Secondary Payer Automation

 

Handling Section 111 reporting, conditional payments, physician peer reviews, and Medicare Set-Asides in separate technology silos leaves room for errors and delays.  Organizations can resolve these problems with a Medicare Secondary Payer solution that automatically and seamlessly connects all compliance, intervention, and MSA processes from the initial identification of a Medicare beneficiary all the way through closure and settlement.

 

An all-encompassing MSP Automation Suite should:

 

  • Capture, store, and manage all data points in a paperless environment
  • Easily integrate with any claims system
  • Enable clients’ business rules to be overlaid onto the vendor’s business processing rules
  • Prompt for missing data
  • Escalate medical and pharmacy issues when triggers occur
  • Initiate and seamlessly track pre-MSA interventions
  • Drive oversight until evidence of treatment changes has been confirmed
  • Provide end-to-end visibility into claims
  • Create an audit trail for each claim
  • Benchmark CMS trends to ensure compliance

 

Tower MSA’s sophisticated technology encompasses all of the above to ensure timely, complete and accurate reporting.  It enables Tower’s legal and clinical specialists to quickly and thoroughly analyze conditional payments and negotiate appropriate reimbursements.  The system even drives and tracks pre-MSA medical and pharmaceutical interventions, which can save hundreds of thousands dollars on a single claim.  Integrating all these processes into a single system ensures 100% MSP compliance, reduces MSA costs and expedites settlements.

————————————————————————————————-

Reducing Future Medicals through Medicare Secondary Payer Automation

 

Workers’ compensation claims continue to be driven by the “cost” of medical benefits.  This is especially the case when dealing with issues of Medicare Set-asides and future medicals in workers’ compensation claims.  This has resulted in many claim management teams to seek service providers who understand this concern and have innovative solutions to satisfy Medicare’s interests.  One such solution is a complete suite of services that cover the entire life of a claim.

 

 

Barriers to Effective Medicare Secondary Payer Compliance

 

Members of the claim management team need to track the movements of files submitted for Medicare Secondary Payer compliance matters.  This is based on the nature of the work being performed by a service provider and its time-sensitive nature.  Common complaints by claim handlers include:

 

  • Lack of creative solutions on the front-end of compliance to reduce the cost of a Medicare Set-aside allocation;

 

  • Inability to track files and determine the status of work being performed; and

 

  • Ineffective communication between the parties to implement cost-saving mechanisms.

 

 

Cost Savings Starts with MSA Triage

 

The concept of “triage” was developed in World War I as a means to better assess a wounded soldiers condition and direct appropriate medical care.  This concept was such a success that it has been applied successfully to other areas, including Medicare Secondary Payer compliance.  By using an effective case triage model, a Medicare Secondary Payer service provider is able to review a case and identify barriers that may delay settlement.  The net result is real savings to the claim management team through a better reserve system and efficiency in settlements.

 

 

Effective Medicare Secondary Payer Case Management

 

An effective Medicare Secondary Payer service provider will also implement strategies for cost savings beyond the initial in-take and triage phases.  These additional steps strive for efficiency via computer-based technologies that include assistance with the following matters:

 

  • Physician peer review;

 

  • Drug utilization review; and

 

  • Clinical oversight.

 

A fully automated process should make case specific recommendations for further intervention when reasonable and necessary.  These suggestions will result in the lowest defensible Medicare Set-aside allocation.  The use of these system processes will also keep the claim handler involved in the process and allow for greater transparency.  This includes the identification of missing data elements, conditional payment searches/resolution and medical/pharmaceutical interventions.

 

 

Other Benefits to Complete Medicare Secondary Payer Automation

 

Automation of Medicare Secondary Payer compliance services offer members of the claim management team a number of benefits.  From the onset of the claim, it provides the opportunity for the client to receive front-end services that reduce costs over the life of a workers’ compensation claim.  Other attributes include:

 

  • A holistic approach that ensures consistency in Medicare Secondary Payer compliance services;

 

  • Moves the claim forward through the final step of compliance, which is Section 111 Mandatory Insurer Reporting; and

 

  • Allows for 24/7, end-to-end visibility that keeps the workers’ compensation claims team engaged and updated during the entire compliance process.

 

 

 

Conclusions

 

Medicare Secondary Payer compliance services are moving beyond providing clients with an a la carte list of services.  More advanced service providers are able to offer solutions throughout the entire life of a claim.  This also allows members of the claim management team to be active in the claim and aware of what is taking place.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Understanding Medicaid Recovery in Workers’ Compensation Settlements

The expansion of Medicaid under the Affordable Care Act (ACA) is starting to impact workers’ compensation settlements nationwide.  This is based primarily on the new pressures placed on state health programs who administer these programs.

 

 

What is Medicaid?

 

Medicaid came into existence at the same time as the Medicare program.  While there are some similarities between the two government programs, they should never be confused.  Medicaid is a state-based health program, which receives part of its funding and coordination from the federal government.  The Medicaid program has some unique differences that provide healthcare for millions of Americans.

 

Prior to implementation of the ACA, Medicaid served only low-income individuals with a disability.  Since 2014, persons with an income up to 133% of the poverty line to qualify for coverage.  This also includes adults without dependent children.  Individuals receiving Medicaid can also be eligible for Medicare.

 

 

Medicaid Recovery in Workers’ Compensation Cases

 

Due to the fact that Medicaid is mainly a state-government program, federal regulations had little impact on the ability of these programs to recover for medical funds related to medical care and treatment in workers’ compensation cases.  This is an area where significant changes in law have been made on the federal level, which will impact your cases.

 

Arkansas Department of Human Services v. Ahlborn, 547 U.S. 268 (2006), represents an important case related to the rights of recovery for state Medicaid programs.  In this case, the Arkansas Department of Human Services sought 100% recovery of funds paid on behalf of a personal injury victim.  Based on the settlement amounts and costs for associated medical care, this practice would have nearly taken away all of the available settlement monies and left the injured party without compensation.  In a unanimous decision, the Court held this program could not recovery against a plaintiff related to portions of their settled attributable to pain and suffering or wage loss.

 

 

Post-Alborn and Congressional Action

 

Notwithstanding this settlement, state programs have continued to seek reimbursements in these cases.  This has included congressional action that threatens workers’ compensation settlements and insurance carriers who make payments to injured parties.

 

In early 2014, Congress passed a series of amendments to the Social Security Act that covers Medicaid.  This law is sometimes referred to as “Section 202 of the Bipartisan Budget Act of 2013,” or the “Medicaid Secondary Payer Act.”  Under this law, state programs were given additional recovery opportunities that overrode the unanimous Alborn decision preventing recovery against the non-medical aspects of a personal injury or workers’ compensation claim.  The effective date of these provisions was initially October 1, 2014.  The law was later amended to move that date out two years.

 

 

Ramping Up Enforcement in the States

 

Several states have taken their new recovery powers seriously and are ramping up their enforcement and recovery efforts in anticipation of full-fledged Medicaid Secondary Payer becoming effective on October 1, 2016.  These states include Rhode Island, Kentucky and Mississippi.  The initial steps in this process includes sending warning letters to attorneys and members of the claim management team.

 

 

Practice Pointers

 

Claim management teams need to be proactive when dealing with issues related to Medicaid recovery.  This can include the following:

 

  • Proactively identify claims who potentially will become Medicaid beneficiary, or who are beneficiaries at the time of the claim.
  • Identify and place appropriate state agencies on notice of their potential intervention rights.
  • Keep all parties updated regarding Medicaid recovery efforts and include the appropriate government officials in your settlements.
  • Continue to stay updated regarding changes in Medicaid Secondary Payer recovery.

 

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, and founder of COMPClub an interactive training program teaching workers’ comp cost containment best practices.  Through this platform he is in the trenches on a monthly basis with risk managers, brokers, consultants, attorney’s, and adjusters teaching timeless workers’ comp cost containment strategies, as well as working with members to develop new tactics and systems to address the issues facing organizations today. This unique position allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

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