Medicaid Recovery Rights – What You Need to Know

It’s been characterized as “almost unintelligible to the uninitiated,”  and it’s about to further complicate things in the workers’ compensation system. As of October 1, state Medicaid programs are allowed to assert a full recovery against all amounts paid to a claimant.

 

We can most likely expect states to ramp up their reimbursement efforts for affected workers’ compensation claims. It means if you haven’t paid much attention to Medicaid’s secondary payer recovery rights, it’s time to start.

 

 

Medicaid

 

Similar to Medicare, Medicaid provides healthcare to certain Americans. But unlike Medicare, Medicaid involves both the federal and state governments — think workers’ compensation with some federal oversight.

 

Here are some of the specifics of Medicaid:

 

  • Expansion. It was created by Congress to provide healthcare to the disabled and those living in poverty, but was expanded under the Patient Protection and Affordable Care Act. Just about anyone under 65 who has a household income under 133 percent of the federal poverty level is now eligible.
  • Quasi-federal/state program. States administer eligibility and claims processing functions, while the federal Centers for Medicare & Medicaid Services (CMS) oversees state compliance with federal Medicaid rules.
  • Voluntary. The voluntary program allows states to determine how to address the needs of their own populations; but they must adhere to rules established by CMS in order to receive some federal funding for the program.
  • Needs based. Unlike Medicare, which is an entitlement program generally available to anyone over 65 and/or disabled, Medicaid is based on a person’s income level.

 

 

Secondary payer

 

Like Medicare, Medicaid is designed to be the payer of last resort and its interests are supposed to be considered in settlements. However, court decisions over the years have limited reimbursement to only the amount designated for medical care, something not typically identified in workers’ compensation claims. That’s made it more difficult for states to go after settlement money. Until now.

 

The October 1 change allows Medicaid programs to go after the entire settlement of program beneficiaries. Just as Medicare has the right to recover conditional payments made from settlement amounts, Medicaid will likewise impact claims resolution. In fact, one of the federal government’s Medicaid requirements has been for states to seek reimbursement from third party sources. The October 1 change simplified that process — at least, for Medicaid agencies.

 

 

Workers’ Compensation

 

Because Medicaid programs are administered by states, every jurisdiction has a different set of laws and regulations — similar to workers’ compensation; and Medicaid recovery rules also vary from state to state. That fact complicates the situation for employers that operate in multiple states, as they try to determine Medicaid’s rights of recovery.

 

What the change will mean for workers’ compensation is something of a mystery at this point, at least in terms of the specific steps to consider Medicaid’s interests in settlements. Many questions need to be answered, such as reporting requirements, compliance and repayment.

 

One issue that further complicates things is the fact that recovery for Medicare and Medicaid are not mutually exclusive; each must be considered at settlement. Estimates are that roughly 20 percent of Medicare beneficiaries also collect benefits from Medicaid programs.

 

In anticipation of the rule change, states began the process of implementing strategies to identify Medicaid beneficiaries who receive workers’ compensation. Many state Medicaid agencies have implemented reporting requirements through data exchange programs and registries.

 

Rhode Island, for example, established the Medical Assistance Intercept System and requires all insurers operating in the state to participate. The program electronically matches Medicaid recipients with liability and workers’ compensation insurance claims. It is designed to intercept payments of $500 or more for reimbursement to the state’s Medicaid program.

 

 

What to Do

 

  1. Proactively monitor developments. Watch for CMS guidance, for example to understand how best to comply with reporting requirements and compliance.
  2. Understand state laws. It’s important to stay abreast of Medicaid recovery statutes and case law in each jurisdiction in which you do business, since each one has a unique system.
  3. Identify Medicaid beneficiaries and those who will be, among your claimants, and report them to your state’s Medicaid agency.
  4. Don’t forget Medicare. The rule change for Medicaid has no bearing on Medicare, so procedures for considering its interests should remain the same.
  5. Carefully read any correspondence you receive from CMS and/or state Medicaid agencies.
  6. Adopt best practices. Work with your attorney(s), carrier and claims managers to develop a plan to consider Medicaid’s interests in claims.

 

 

Conclusion

 

Medicaid has always been a payer of last resort when other sources of funding are involved. The change in language as of October 1 will likely lead states to become more aggressive in seeking recovery in claims involving Medicaid beneficiaries. It’s important to stay up to date on the very latest developments to ensure you are in full compliance.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 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.

Case Study: $774,583 in Work Comp Savings through MSA Triage

Medicare Secondary Payer compliance has created several challenges for interested stakeholders in workers’ compensation programs that seek to reduce cost and improve efficiencies.  One of the common failures of many workers’ compensation programs when it comes to building an effective compliance program is the inability to assess the situation, prioritize troublesome files and position those files for settlement.  Now is the time to change the direction of your program and reduce costs by considering a triage process that is similar to how emergency rooms treat patients when they come through the door.

 

 

Emphasis on Case Triage and Care Prioritization

 

Applying the concept of triage to files involving Medicare Secondary Payer compliance matters is important when it comes to prescription drugs, which has been a main cost driver since the addition of the Medicare prescription drug benefit in 2006.  This allows a workers’ compensation program to understand the exposure and take effective steps to mitigate the future risks.

 

 

Implementing an Effective Triage Program to Reduce Program Costs

 

Like an injured person entering the emergency room, an MSP compliance case requires triage to assess the condition and effectively guide care.  Recommendations can also be made to reduce future exposures through the implementation of an effective plan.

 

  • Use a clinical team to review and understand the employee’s complex medical issues;

 

  • Understand state specific rules for prescription drug use, in conjunction with evidence based medicine to ensure best practices are included in the treatment/drug weaning plan; and

 

  • Evaluate the need for the recommended future medical care and treatment and take the necessary next steps to reduce program costs.

 

By taking the above steps, a proactive workers’ compensation program can coordinate care with the employee’s treating doctor.  This can include the removal of certain future care recommendations, implement steps to reduce prescription drug usage or change certain drugs from name-brand medications to generics, which are often less expensive.  The result of early case evaluation and triage can ensure quicker employee recoveries, promote settlement and add savings to a workers’ compensation program.

 

 

CASE STUDY (Provided by Tower MSA Partners): $774,583 in Savings from Pre-MSA Triage

 

Challenge:

 

Case submitted to Tower for Pre-MSA Triage to assess Medicare exposure.  In 2010, worker was doing electrical line work when he was struck by lightning.  Injuries included electric shock with pain, insomnia, depression and seizure activity.  Treatment included prescription drugs as follows:  Hydrocodone/APAP (7.5 / 325 mg at 4 / day), Baclofen (muscle relaxant), Topamax (anti-seizure), Cymbalta (anti-depressant), Keppra (anti-convulsant), Naproxen (pain), Clonazepam (anti-anxiety).  Cost drivers included Keppra and Topamax, both with generic available, but being prescribed, filled and paid by carrier as brand.

 

Total MSA Exposure – $1,416,513. 

 

 

Solution

 

As part of the standard Pre-MSA Triage process, Tower’s clinical team identified the key cost drivers, made recommendations within the context of the state of jurisdiction to optimize the drug regimen, documented recommendations to achieve the desired result, and calculated the optimized MSA value at $641,930.

 

In this case, recommended next steps included Tower’s Physician Follow Up service to contact the injured worker and treating physician to request a change from ‘Brand’ to ‘Generic’ formulation for Topamax and Keppra. Tower’s legal team worked with defense to facilitate the switch by obtaining attestation of acceptance of the generic formulation by the injured worker (he had previously requested brand), then communicating with the prescribing physician to obtain written confirmation of the substitution of generic formulations of both drugs for the previously prescribed brand drugs.

 

 

Results:

 

With client approval, Tower used the information prepared with the Pre-MSA Triage, added the attestations obtained from both injured worker and physician noting that substitution was allowed for both Topamax and Keppra and finalized the MSA for submission to CMS.

 

In its review, CMS accepted the attestations as confirmation of the change in drug therapy and approved Tower’s submitted MSA at $641,930.

 

Total savings = $774,583.

 

 

Conclusions

 

Changing the mindset of a workers’ compensation claims program needs to include the willingness to explore options when it comes to Medicare Secondary Payer compliance.  Using a triage program on all files where future medicals are part of the equation adds value to a claims management program and promotes savings.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, CEO 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 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.

Practical Implications of the Revised CMS WCMSA Reference Guide

Earlier this month the Centers for Medicare and Medicaid Services (CMS) released a revised Workers’ Compensation MSA Reference Guide (WCMSA) (find Version 2.6 here) with several notable changes and additions impacting its review of MSAs in workers’ compensation cases. The Tower MSA compliance team has taken some time to review and consider not only the substantive impact these changes have on our processes, but the implications for our clients. Please find below a summary of the notable changes to the Reference Guide along with practical implications.

 

 

Recognition of a Hearing on the Merits of the Case (Section 4.1.4)

 

The relevant change to this section is as follows:

 

Because the CMS prices based upon what is claimed, released, or released in effect, the CMS must have documentation as to why disputed cases settle future medical costs for less than the recommended pricing. As a result, when a state WC judge or other binding party approves a WC settlement after a hearing on the merits, Medicare generally will accept the terms of the settlement, unless the settlement does not adequately address Medicare’s interests. This shall include all denied liability cases, whether in part or in full . . .

 

 

Practical Implications:  Over the years CMS has had several definitions of under what circumstances it will recognize a hearing on the merits, but the takeaway has consistently been that CMS gives itself complete discretion as to whether or not it will recognize a particular judicial decision, order or finding as limiting the MSA. Some commentary in response to the Reference Guide revisions has indicated the changes found in this section will result in Zero MSAs based upon a complete claim denial no longer being approved without a hearing on the merits confirming the basis for the denial. We are not certain this is the correct inference to draw from this change. This section addresses the effect of a hearing on the merits of a case to the projection of future medical care. If there is no hearing on the merits of the case, which is the situation in most MSA submission, Zero MSA or otherwise, then this section should have no applicability to CMS’s review of a Zero MSA.

 

Tower MSA’s plan is to stay the course on the long-used criteria for a Zero MSA based upon a claim denial unless and until we identify any changes through the MSA submission process which requires modification to these criteria.

 

 

Recognition of State-Specific Statutes (Section 9.4.5)

 

The relevant change to this section as follows:

 

Submitters requesting alteration to pricing based upon state-legislated time limits must be able to show by finding from a court of competent jurisdiction, or appropriate state entity as assigned by law, that the specific WCMSA proposal does not meet the state’s list of exemptions to the legislative mandate. For those states where treatment is varied by some type of state-authorized utilization review board, the submitter shall include the alternative treatment plan showing what treatment has replaced the treatment in question from the beneficiary’s treating physician for those items deemed unnecessary by the utilization review board. Failure to include these items initially will result in pricing at the full life expectancy of the beneficiary or the original value of treatment without regard to the state utilization review board recommendation.

 

 

Practical Implications – State-Legislated Time Limits: Similar towards its policy on recognizing decisions stemming from hearings on the merits, CMS has consistently given itself complete discretion as to when it will recognize any state statute as providing a limitation on the medical care allocated in the MSA. Experience has shown CMS to be unwilling, under most circumstances, to recognize a state statute as having the affect of limiting medical care in the MSA. A notable example is the Georgia statutory provision limiting an employer’s responsibility for medical care to 400 weeks post the date of injury in non-catastrophic claims (applicable to cases with DOIs of 7/1/2013 and later). We have yet to see an instance where CMS has agreed to limit the MSA amount based upon this statute.

 

The changes to this section of the Reference Guide provide hope that CMS may be more open to recognizing state statutes, like Georgia’s, as a basis for limiting medical treatment and medications in the MSA. Unfortunately, the requirement “to show by a finding from a court of competent jurisdiction . . . that the specific WCMSA proposal does not meet the state’s list of exemptions to the legislative mandate” presents a challenge in attempting to use a statutory provision to limit the MSA. For example, in Georgia a workers’ compensation case is by default considered non-catastrophic unless accepted by the employer or carrier as catastrophic or the claimant’s attorney submits to the Georgia Workers’ Compensation Board a request for the claimant to be designated as catastrophic. It is unclear at this point whether confirming the non-catastrophic nature of the claim in board approved settlement documents or a separate finding by the board that the claim is non-catastrophic will be sufficient for CMS to recognize the limitation. Based upon our experience with similar types of issues, we expect CMS to require a specific finding separate and apart from the settlement documents. Accordingly, this will require settling parties, whether in Georgia or in other states, to work with their WC board, commission or other judicial authority to provide the necessary finding confirming the claim does not meet any of the exemptions to the statute.

 

 

Practical Implications – Utilization Reviews:  Revisions to this section of the Reference Guide also address the use of URs to limit care in the MSA. According to the requirements delineated by CMS the following must be presented with the MSA submission:

 

UR denial pursuant “some type of state-authorized utilization review board.”
“Alternative treatment plan” from the treating physician showing what treatment has replaced the UR denied treatment or medications.

 

The addition of the language regarding URs raises more questions than it answers. What does CMS define as a UR Board? For example, the California Independent Medical Review (IMR) process, while statutorily created, does not include a UR review board (Although we believe it can be argued that the IMR process is equivalent to such a board). Further, CMS fails to define what would be considered an “alternative treatment plan.” It would seem that an intransigent treating physician could refuse to provide alternative treatment, thus resulting in inclusion of treatment or medications in the MSA denied through the UR process. It is unfortunate CMS added this “alternative treatment plan” requirement as it undermines the very reason a UR process is in place, namely to limit medical care based upon evidence-based treatment guidelines. As Tower MSA submits MSAs to CMS with UR denials we will provide further recommendations as to how CMS is defining a “UR board” and “alternative treatment plan.”

 

 

Addition of “Amended Review” to Re-Review Policy (Section 16.0)

 

As fully explained in the Tower MSA article of 7/12/2017, “Second Chance with MSA Approval!: New CMS Policy Allows for Review of a New MSA Post a Prior Approval,” CMS has introduced what is called an Amended Review process for cases meeting the following criteria:

 

    • CMS has issued a conditional approval/approved amount at least 12 but no more than 48 months prior,

 

    • The case has not yet settled as of the date of the request for re-review, and

 

    Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

Practical Implications:  The Amended Review criteria presents an opportunity to have a second bite at the CMS MSA review apple when it comes to claims which despite having a previously approved MSA, failed to settle medical. It is important to note that the Amended Review process applies not only to MSA determinations resulting in counter-highers, but any MSA determination, approved as submitted or counter-lower, that meets the above-defined criteria. Please contact Tower MSA to discuss eligible claims.

 

 

Added Section on Required Resubmission (Section 16.1)

 

The addition to this section is as follows:

Where a proposed WCMSA amount has been closed due to inactivity for one year or more from the original date of submission, a full-file resubmission will be required.

 

 

Practical Implications: Previously a case closed for inactivity for one year or more would be reopened if the submitter provided the documentation in response to a Development Letter (The most common reason for case closure). CMS is now indicating solely providing the documentation in response to the Development Letter will be insufficient for them to reopen, instead a completely new MSA proposal and supporting documentation will be required. Tower MSA will advise when a case meets the criteria for filing a resubmission.

 

 

Additional MSA Administration Guidelines (Section 17.1)

 

The addition to this section is as follows:

 

Although beneficiaries may act as their own administrators, it is highly recommended that settlement recipients consider the use of a professional administrator for their funds.

 

 

Practical Implications: While not requiring professional administration, this is an acknowledgement by CMS of the difficulties a claimant may face on their own in administering an MSA. Tower MSA agrees with CMS on the benefits of professional administration and when requested by our client will provide MSA professional administration through our partner, Ametros.

 

Other less notable changes found in the Reference Guide apply to clarifying the order of jurisdictional precedence for MSA pricing, updating requirements for spinal cord stimulator pricing, updating off-label medication requirements, clarifying total settlement calculation guidelines and clarification of change of submitter requirements.

 

 

Final Comments

 

While we are pleased CMS is addressing the concerns expressed by Tower MSA and others in the MSP compliance field concerning a second chance at CMS review of an MSA and recognition of state statutory limitations on injury-related medical care, the real test will be in the coming weeks and months the affect these revisions have on the review of MSAs submitted to CMS for approval. Tower MSA continuously monitors these responses and will provide our clients appropriate guidance on the impact, or lack thereof, of these revisions and additions to the WCMSA Reference Guide.

 

 

 

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

Accuracy in Section 111 Reporting of ORM Vital to Avoiding Unnecessary Repayment Demands from Medicare

While the Commercial Repayment Center (CRC) has faced some valid criticism over the course of the past year and half in relation to its recovery efforts on behalf of the Centers for Medicare and Medicaid Services’ (CMS), not all problems start with the CRC. CRC’s recovery efforts are driven by the data employers, carriers and self-insured entities report to Medicare through the Section 111 Mandatory Insurer Reporting process. Chief among the data elements reported is acceptance of Ongoing Responsibility for Medicals (ORM) and the termination thereof. If this data is reported inaccurately or there is a failure to report required data, then the applicable plan may be faced with inappropriate recovery demands by the CRC.

 

 

Applicable Plan Reporting of ORM is the Catalyst for CRC Recovery Efforts

 

Since October 5, 2015, the CRC has had responsibility for the recovery of conditional payments where the insurer or employer (including self-insured entities) is the identified debtor, known in CMS terms as the “applicable plan.” The CRC learns of opportunities to recover through the Section 111 Mandatory Insurer Reporting process. In other words, the applicable plan is the catalyst for Medicare conditional payment recovery by its reporting of ORM.

 

The mandatory reporting provisions of the Medicare Secondary Payer Act require the applicable plan to report to Medicare in three instances – the acceptance of ORM, the termination of ORM and issuance of a Total Payment Obligation to the Claimant (TPOC), settlement judgment, award or other payment. In regard to ORM, two key data elements reported are the date responsibility for ORM is accepted and the accepted diagnosis codes. Once this information is reported the following actions are initiated by CMS’s contractors:

 

  1. The BCRC, which handles Medicare coordination of benefits, should deny payment for medical bills submitted for payment in which the billed diagnosis codes match or is similar to the reported diagnosis codes.
  2. The CRC identifies medical claims that Medicare has paid that it deems related to the reported diagnosis codes.

 

Upon the CRC identifying treatment related to the reported diagnosis codes, it will issue a Conditional Payment Notice (CPN) to the applicable plan which itemizes charges deemed related to the injury. The applicable plan has 30 days from the date on the CPN to dispute charges after which a Demand Letter will issue demanding repayment for the charges identified by the CRC. A Demand Letter provides 120 days from receipt of the letter for the applicable plan to appeal all or some of the charges or issue payment. If payment is not issued within 60 days of receipt, interest begins to accrue from the Demand Letter date.

 

 

Reporting Accurate Acceptance of ORM and Diagnosis Codes

 

The trigger for reporting ORM is a claimant identified as a Medicare beneficiary and the assumption of ORM by the applicable plan. ORM is reported when the applicable plan has made a determination to assume responsibility for ORM, or is otherwise required to assume ORM—not when (or after) the first payment for medicals under ORM has actually been made. Accordingly, the ORM acceptance date is typically the date of injury.

 

Along with the ORM acceptance date, at least one ICD-10 diagnosis code must be reported for the diagnosis that has been accepted on the claim (If more than one diagnosis has been accepted, then additional diagnosis codes are reported). While medical provider billing records are often used to determine ICD-10 diagnosis codes to report, these should be used as a starting point, not an ending point, in identifying the correct codes to report to Medicare.

 

Keep in mind that medical providers, and especially hospitals, will often insert into billing records any diagnosis reported to the provider, which are not necessarily the same diagnoses that are being accepted on the claim. Consequently, the person responsible for determining the correct ICD-10 diagnosis code to report, usually the claims handler, must make an independent determination, separate and apart from the medical provider, as to whether the particular diagnosis is being accepted on the claim. If the billing records do not properly represent what is being accepted, or if further diagnosis codes are required to better define what is accepted, then online ICD-10 resources are available to identify codes which correctly represent the accepted body parts and conditions.

 

Once ORM and the diagnosis codes are reported, ORM is generally not addressed again until the date of ORM termination. However, causally related diagnoses may change over time, either expanding or retracting depending upon the circumstances in the claim. Accordingly, it is important to update the reported ICD-10 codes as necessary over the course of the claim.

 

 

ORM Termination Key to Cutting Off Liability to Medicare

 

Once ORM is accepted, CMS claims the right to recover against the applicable plan through the date of ORM termination. As such, recovery efforts by the CRC may happen years after the ORM was first reported. Further, if there is failure by the applicable plan to terminate ORM when appropriate, then the plan may receive repayment demands from CRC for time periods in which it has no liability to pay for medical treatment. An applicable plan may terminate ORM through the Section 111 Reporting process under the following situations:

 

Settlement with a release of medicals

No fault policy limit reached

Complete denial of the claim

Statute of limitations has run or medical benefits have otherwise been exhausted pursuant to state law

Judicial determination after a hearing on the merits finding no liability

Statement from treating physician – signed statement from the injured individual’s treating physician that he/she will require no further medical items or services associated with the claim/claimed injuries.

 

Keep in mind that closing a claim file is not a trigger for ORM termination unless it is accompanied by one of the above situations.

 

Providing CMS with an ORM termination gives a bookend to recovery by the CRC. If no termination date is provided, then CRC assumes the applicable plan remains liable for injury-related payments.

 

 

Recommendations for Ensuring Accurate ORM Reporting

 

The reporting of ORM acceptance and termination and defining accepted diagnosis codes is so important because it is the applicable plan’s admission of responsibility to pay for medical care during the reported time period and for the reported diagnoses. If an error is made in reporting or there is an omission in reporting, then it can result in attempts by Medicare to recover for conditional payments unrelated to the injury or for time periods during which the applicable plan is not liable. Errors in reporting can also lead to inappropriate denials in the payment of claimant’s medical care by Medicare or Medicare paying for medical care for which the applicable plan is responsible.

 

 

Recommendations to avoid these errors and omissions:

 

  1. Train Claims Handlers on ORM Reporting: If a claims handler is responsible for inserting the data required for ORM reporting, then they require training as to when ORM acceptance and termination is to be reported and how to determine the appropriate diagnosis codes to report with ORM acceptance.
  2. Effective Quality Assurance of ORM Reporting: Even with training, errors will occur. Additional resources placed into quality assurance of ORM reporting, such as double-checking claims for proper ORM termination and appropriate diagnosis code choices avoids the expenditure of additional resources at a later date to correct errors in reporting and correction of unnecessary recovery demands from the CRC. If you are an employer or carrier relying upon a TPA to report, it is especially recommended that a QA process be in place to check the data entered by the TPA.
  3. Ensure Reporting Platform is Accurately Reporting: Section 111 Reporting is electronically based and requires a data exchange with Medicare. Errors can and will occur in this data exchange. Ensure you have a trusted and reliable reporting agent to assist with accurate reporting to Medicare.

 

Finally, if any correspondence is received from the CRC or the U.S. Treasury Department claiming conditional payment recovery it must be acted upon immediately. Do not assume the letter was issued in error and will simply go away. If you do not believe you are liable for the conditional payments for which the CRC is claiming recovery, first confirm you have correctly reported ORM and then work with your MSP compliance partner to appropriately dispute the charges.

 

 

 

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.  For questions stemming from this article please contact Dan Anders at (888) 331-4941 Daniel.anders@towermsa.com.

Second Chance with MSA Approval: New CMS Policy Allows for Review of a New MSA Post a Prior Approval

While there may be no second chances in life, there is now a second chance for CMS review and approval of an MSA. On July 10, 2017, the Centers for Medicare and Medicaid Services (CMS) quietly rolled out a new policy allowing for a re-review of a previously approved Medicare Set-Aside which is between one and four years post-submission and for which there is a certain dollar amount change in projected future medical care since that time. The policy, which CMS calls an Amended Review, requires the previously approved MSA meet the following criteria:

 

 

  • Must have been originally submitted between one and four years from the current date.
  • Cannot have a previous request for an Amended Review.
  • Must result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount (The amount can be greater or less than the previously approved MSA amount).

 

 

CMS also notes that while you may change from brand-name to generic drug types, this change cannot be the sole reason for the Amended Review request. You must include additional changes such as changes in dosage and/or frequency, additional drugs or drugs no longer taken to qualify for the Amended Review.

 

A copy of the policy can be found in Section 12.4.3 of the revised Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) User Guide found here.

 

 

Practical Implications of Amended Review Policy

 

Prior to this new policy, CMS, in almost all cases, would not review a new MSA proposal based upon post-submission medical records and pharmacy history once an MSA was approved. Consequently, if parties were unable to settle a case because of a high CMS MSA approval, but came back to the settlement table a couple years later when the claimant’s medical care had subsided, they were unable to obtain a revised MSA approval from CMS which would accurately reflect the claimant’s current and future course of medical care. Under this new policy, these cases which are within 1-4 years post the original MSA submission and meet the 10% or $10,000 (whichever is greater) criteria will have a second chance at CMS review and approval of an MSA.

 

 

Unanswered Questions Regarding Policy

 

As with many a new policy CMS left some unanswered questions.

 

It is unclear why CMS limited the Amended Review policy to submissions made within four years. We assume this is to limit the number of MSAs submitted for an Amended Review, but there remain cases older than four years which would benefit from this policy.

 

 

While we do not like to look a gift horse in the mouth, it seems unreasonable of CMS to preclude from its Amended Review policy requests which are based solely upon a brand name medication going generic or a claimant otherwise switching to a generic medication. This type of change often results in a significant reduction to the MSA.

 

 

The 10% or $10,000 change (whichever is greater) policy effectively means that there must be a $10,000 change to a previously approved MSA of $100,000 or less before it meets the criteria for an Amended Review. However, the example CMS provides in the User Guide inaccurately reflects a change on an $80,000 MSA of $8,000 as meeting the Amended Review criteria. We believe either the policy or the example is in error. We await CMS correcting this example or clarifying its policy.

 

 

Does My Case Fit the CMS Amended Review Criteria?

 

The Amended Review criteria opens the door to the settlement of some older cases where prior CMS approved MSA amounts no longer accurately reflect the claimant’s current and future course of medical care. Please feel free to reach out to Tower MSA Partners for an evaluation as to whether your previous CMS approved MSA may meet the Amended Review criteria. Tower MSA may be contacted at info@towermsa.com or (888) 331-4941.

 

 

Additional Changes in Updated WCMSAP User Guide

 

Besides the introduction of the Amended Review policy, CMS also made the following notable changes to the WCMSAP:

 

 

  • Claimants who are Medicare beneficiaries now have access to the WCMSAP through MyMedicare.gov. Accordingly, claimants are able to view MSA submissions and supporting documentation although will not be able to modify the documentation or otherwise take any actions on the submission which remain solely with the submitter of the MSA, i.e. Tower MSA.
  • For MSA submissions that have been closed for more than 12 months (Usually as a result of a non-response to a Development Letter), an entirely new MSA submission must be made with all documents generally required of a new MSA submission, i.e. two years of medical records. The new MSA submission will be assigned a new Case Control Number.

 

 

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

 

Case Study: 60% MSA Savings From CMS Re-Review Process

While the Workers’ Compensation Medicare Set-Aside (WCMSA) review process remains voluntary, it is an excellent tool to provide certainty in your settlements.  The major downfall of the process is the lack of a formal appeal from an adverse WCMSA decision by CMS.  CMS nonetheless provides a limited “re-review” process which, in the hands of a capable Medicare Secondary Payer service provider, can often yield a favorable result, reducing your MSA costs and helping you realize significant savings.

 

 

Understanding the Re-Review Process

 

If CMS responds to the submission of a WCMSA with a counter-higher (that is, it increases the proposed MSA amount), you can request a re-review in the following instances:

 

  • You believe CMS’ determination contains obvious mistakes (e.g., a mathematical error or failure to recognize medical records already submitted showing a surgery, priced by CMS, that has already occurred); or

 

  • You believe you have additional evidence, not previously considered by CMS, which was dated prior to the submission date of the original proposal and which warrants a change in CMS’ determination (emphasis added).

 

Knowing how to effectively use the re-review process is key and should include using a trusted MSP service partner to drive settlements when CMS disagrees with the original allocation.

 

 

Case Study (Provided by Tower MSA Partners): 60% MSA Savings From CMS Re-Review Process

 

CMS may increase prescription medication allocation in a WCMSA if there are inconsistencies in the medical records or the prescription histories, variances in pricing based upon the fluid movement of Redbook medication pricing, or prescription medications are left open-ended in the medical treatment records. This case study considers the challenge and solution to a re-review presenting both inconsistencies in medical records as well as open-ended prescription medications.

 

 

Challenge

 

CMS countered higher to include Gabapentin 600 mg tablets (AWP-$2.28/per pill), increasing the CMS approved MSA amount to $98,054. The physician had increased prescribed strength from 300mg to 600mg.  However, the injured worker had not filled 600mg prescription. The prescription drug history showed consistent fills of Gabapentin 300 mg capsule (AWP -.03/per pill).

 

 

Solution

 

Tower MSA prepared a letter for submission to the treating physician confirming continued fills of Gabapentin 300 mg capsules. As required in Montana, notice was given to the injured worker and his counsel prior to initiating contact with the physician. The letter was submitted to the physician’s office via fax and was placed on physician’s letterhead and executed by the physician with language as follows:

 

“The above captioned patient is under my care for treatment of chronic back pain and neuropathic pain. He will be prescribed Gabapentin 300 mg capsules taking 2 capsules three (3) times / day to help him manage his pain”.

 

The executed physician letter, which emphasized the consistent history of Gabapentin 300mg refills, was submitted to CMS for Re-Review.

 

 

Result

 

CMS accepted Tower’s physician letter and reduced its CMS approved MSA amount from $98,054 to $33,319, resulting in a savings of $64,735.

 

While CMS stipulates in its guidelines that documentation obtained post CMS submission will not be accepted, the use of the rationale that the injured worker had not filled the 600 mg strength was effective to obtain a positive CMS Re-Review outcome.

 

 

Conclusions

 

The WCMSA review process is unavoidable when the settling parties require the assurance of CMS’s stamp of approval   Claims management teams and other interested stakeholders can save their programs time and money by fully understanding and properly planning and coordinating both the MSA submission and re-review of a counter-higher if necessary.  An experienced MSP service provider is recommended as the planning, coordination, and execution will be included at no additional charge in a best-in-class program.

 

 

 

Michael Stack - AmaxxAuthor Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 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.

Case Study: Obtaining a Legal Zero MSA

There are many barriers to settling workers’ compensation cases that have placed a significant burden on all programs nationwide.  One such barrier is understanding the complexity of the Medicare Secondary Payer (MSP) Act and specifically the voluntary review and approval process for Workers Compensation Medicare Set-Asides (WCMSAs).

 

The stakes are significant in high exposure claims.  This is often the case in high-dollar cases where settlement requires a certain peace of mind by having an allocation reviewed and approved by CMS.  Issues of primary liability can factor into such claims when it comes to receiving a $0 allocation.  In many instances, it is essential to work with a dedicated service provider who knows and understands the components and documentation required to obtain a “Legal Zero MSA” approval.

 

 

Case Study (provided by Tower MSA Partners): Obtaining a Legal Zero MSA 

 

This case study considers the challenge and solution to obtaining CMS approval of a Legal Zero MSA on a completely denied case.

 

 

Challenge:

 

The employee, who is a Medicare beneficiary, allegedly suffered a left medial ankle and foot injury during his employment. At the time of the claimed injury, the claimant was an insulin-dependent diabetic.

 

  • The treating physician opined the injury as a contusion to the left ankle and toe with no evidence of fracture, and the workers’ compensation claim was denied.
  • During the course of post-injury medical care and treatment, the claimant’s uncontrolled diabetes resulted in a below knee amputation.
  • Following the amputation procedure, the claimant sought care from a new physician who concluded ‘in his professional opinion, there was a direct correlation between the traumatic injury he suffered and the below knee amputation’.
  • The workers’ compensation claim denial was affirmed, and $0 MSA was requested.
  • The total potential MSA exposure was $169,053 if the Legal Zero MSA was not approved.

 

 

Solution:

 

Obtaining review and approval of a $0 allocation provides certainty for all parties involved in the WCMSA review and approval process.

 

The solution in this case study required the MSA legal team to work with the defense attorney and client to prepare the Legal Zero MSA by providing evidence as follows:

 

  • The claim was denied in its entirety and in good faith.
  • No payments for medical or indemnity were made.
  • Medical records provided by Plaintiff’s counsel indicate treatment for a severe diabetic condition dating prior to the 06/25/2014 alleged injury.
  • Formal denial filed to the North Carolina Industrial Commission stating that the claim is denied as the medical records received thus far do not substantiate relationship of any injury on 06/25/2014 to his complaints.

 

 

Results:

 

In its review of the evidence provided by the legal team, CMS concurred with the evidence as proof of no liability and the Legal Zero MSA was approved in full by CMS.

 

Savings achieved in this case totaled $169,053

 

 

Conclusions:

 

The stakes are high when it comes to obtaining a $0 allocation during the voluntary WCMSA review and approval process.  Failing to work with an experienced MSP service provider who understands the process can result in delays, missed settlement opportunities and cases not settling, which will only add costs to your workers’ compensation program.

 

 

Author Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2017 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.

Denied Claim Zero MSAs: Still Available, But Put Through Wringer by CMS

In October 2016, CMS made an unannounced policy change which effectively eliminated the ability to obtain a Zero MSA approval from CMS based upon a complete denial of the claim, without a supporting judicial decision. After only a couple weeks, CMS withdrew this policy change and again allowed for approval of Zero MSAs based solely upon a complete claim denial. Nonetheless, these Zero MSAs reviews are placed through the proverbial wringer by CMS such that it is important to understand when a case meets the criteria for a Denied Claim Zero MSA and the documentation required to obtain CMS approval.

 

 

Denied Claim Zero MSA Approval Criteria

 

A Denied Claim Zero MSA (or Legal Zero MSA) approval from CMS is available when the claim has been completely denied with no medical or indemnity payments having been made with the exception of medical payments made for non-treatment purposes such as IMEs, case management and medical records copies (Note, in certain limited situations a Zero MSA may be approved with medical treatment payments having been made. Please consult with Tower MSA).

 

Importantly, CMS will not approve a Denied Claim Zero MSA if settlement is made final and/or a settlement payment or any medical or indemnity payment is made prior to CMS approval of the Zero MSA. A tentative or agreed to settlement is allowable, but please do not make the settlement final or make indemnity or medical payments prior to CMS approval of the Zero MSA.

 

If the case meets this criteria, then CMS has strict documentation requirements which must be adhered to or the Zero MSA will be rejected. Notably, since the policy change and rollback occurred in October 2016, CMS has added a requirement to provide claim reserve documentation. The requirement for claim reserve documentation, as well as all other supporting documentation, is detailed below.

 

 

Denied Claim Zero MSA Documentation Requirements

 

The following documents are required by CMS to obtain approval of a Zero MSA based upon a complete claim denial:

 

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. Print or run date listed on the printout.
  • Date range for listed payments – Must be since inception of claim.
  • If the Claim Payment History does not meet the above requirements, then the following rules apply:

 

Provide a copy of the available Claim Payment History with the following statement inserted, signed and dated in the document:
This document provides a complete representation of all payments made on the life of the claim (including medical of $0* and indemnity of $0)

 

Signed:
Date:

*If medical payments were made, provide the invoices or reports, i.e. IME report, associated with those payments and see below Financial Detail and Denial Letter requirement.

 

  • Letter providing an explanation why a Claim Payment History meeting CMS’s requirements is not available (See below Financial Detail and Denial Letter)

 

2. Claim Reserves

 

  • A Claim Reserves printout divided into categories for medical, indemnity and expenses with subtotals for each category and a grand total.
  • Print or run date listed on the printout.
  • If there is a legal argument for claiming the reserve information is privileged then the legal argument, including citations to statute or case law must be provided along with a copy of a redacted (reserve information blacked out) version of the Claim Reserves printout.
  • If no reserves were placed on the claim, then a statement regarding the same.

 

3. 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).

 

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

 

5. Financial Detail and Denial Letter – Tower MSA will provide draft letter upon request for submission of the Zero MSA to CMS

 

  • A statement indicating the claim was completely or fully denied with no medical or indemnity payments having been made.
  • If medical payments have been made for non-treatment purposes, i.e. IME, case management, medical records requests, then if the Claim Payment History does not properly explain the purpose of these payments, then provide an explanation for the payments.
  • If the available Claim Payment History does not meet the requirements under #1, then state that the carrier’s claim system does not have the ability to provide a Claim Payment History printout with the information requested by CMS, i.e. print date, subtotals for medical, indemnity and expenses.
  • If Claim Payment History did not meet the requirements under #1, then insert the requested information into the letter, i.e.list categories for medical, indemnity and expenses with subtotals for each category and a grand total.
  • If there are no draft or final settlement documents and no court orders or rulings, then a statement regarding the same.
  • If there is no First Report of Injury, then a statement regarding the same.
  • Letter must be placed on letterhead and hand signed.

 


6. Consent to Release form executed by claimant

 

While CMS places Zero MSA submissions based upon a complete denial through the wringer, these approvals remain available for workers’ compensation cases meeting the applicable criteria.

 

 

Author Rita Wilson, CEO, Tower MSA Partners, LLC. Rita serves as CEO of Tower MSA Partners, LLC. With more than 20 years in leadership positions in pharmacy software development and workers’ compensation managed care, Rita brings a wealth of expertise in information technology solutions and performance metric evaluation. Contact Tower MSA Partners at referrals@towermsa.com or (888) 331-4941

Identify and Realize Medicare Set-Aside Savings Opportunities

The rising costs of workers’ compensation come in many different forms.  One such way members of the claims management team are seeing these increases is in Medicare Set-aside allocations and future medicals.  This issue presents a challenge for all teams and to meet this challenge a MSA service provider should be utilized that employs creative tools to reduce an allocation in a reasonable and ethical manner.  One such mechanism is the use of physician intervention by following up with the employee’s treating physician to confirm the accuracy of all treatments and prescriptions drugs in the allocation.

 

 

Back to the Basics of MSA Allocation Preparation

 

There is a certain art to preparing and writing a MSA allocation.  This includes the threshold matter of ensuring the allocation is reasonable, and will be accepted if it is sent for voluntary review and approval by CMS.

 

When writing an accurate MSA allocation, the person preparing the report will rely on some or all of the following materials and records:

 

  • All medical records for the last two years of treatment related to the WC claim*;
  • A complete claim payment history record from the insurance carrier;
  • A separate pharmacy payment history report;
  • Draft settlement documents, prior settlements, court orders and decisions and other legal documents;
  • A First Report of Injury; and
  • Explanation of accepted, disputed and denied body parts, along with ICD-10 codes.

 

* “Treatment records” consist of all medical records for treatment to the claimed body part or condition even if the employer or carrier did not pay for the treatment.  Also, CMS does not consider an Independent Medical Examination report a “medical record” for purposes of allocation review and approval.

 

 

Cost Drivers in MSA Allocations

 

Medical costs in workers’ compensation claims continue to rise with a large portion of future medical tied to pharmacy costs. A September 2016 NCCI research brief states “for every $100 of medical services paid on claims older than 10 years, approximately $45 to $50 will be for prescription drugs.” This leads to an increased future medical component that must be considered as a part of every settlement.  Members of the claims management team should monitor their files for the following issues:

 

  • Pharmacy savings opportunities: Medications that are prescribed, but never actually filled by the employee, prescribed medications that have been discontinued, and brand name drugs that can be replaced with generics.

 

  • Medical savings opportunities: Ongoing and prolonged treatment by a primary care doctor for injuries that should require a specialist, gaps in a patient’s medical record and treatment recommendations which are no longer considered viable, such as a spinal cord stimulator.

 

 

Physician Intervention – Brand vs. Generic Drugs

 

There are many opportunities for members of the claim management team to reduce the cost of a MSA allocation and promote a culture of settlement.  One such strategy is directly contacting the employee’s treating physician to follow up on medical cost driver red flags and savings opportunities.  As a note of caution, this should be done in conformance with federal and state law and may require the approval of the injured worker.

 

A classic example of when direct physician intervention is appropriate comes after a review of prescription records.  Often the physician prescribes a certain brand name medication versus a therapeutically equivalent generic.  While not always the case, generics are often considerably less expensive and offer the same medicinal attributes as the brand name.

 

An experienced MSA service provider will notice this opportunity by reviewing the “dispense as written” (DAW) codes in medical and pharmacy records.  They will position your file for the cost-saving measure to recommend direct contact with the physician to revise the prescription for the cheaper alternative.  Communication between the parties allows the necessary change to occur.  The cost savings will be realized once that cheaper alternative is filled by the pharmacy and a paper trail is created.  This allows the allocator to document the file and justify the lower prescription drug costs.

 

 

Physician Intervention – Discontinued Medications

 

Another opportunity for MSA cost reduction is to identify and confirm the discontinuation of medications previously prescribed.

 

Medicare Set-asides: A Case Study

 

 

*case study provided by Tower MSA Partners

 

 

The main cost driver in this MSA allocation was the cost of prescription drugs.  In the above example, a review of the pharmacy recorded revealed Amitiza, Pantaprazole, and Meloxicam were prescribed, but had not been filled for an extended period of time. This represented a significant opportunity for savings by directly following up with the treating physician in writing to confirm these prescriptions had been discontinued. This confirmation allowed the prescriptions to be removed from the allocation, resulting in $200,113 in savings.

 

 

Conclusions

 

The ever-increasing price of medicals on workers’ compensation presents a series of challenges for the claims management team.  In order to avoid over-allocating for treatment and prescription medications, leverage a proactive MSA service provider to identify MSA savings opportunities and intervene with the treating physician.  This proactive approach often results in a lower MSA allocation with realized cost savings to the claims management team.

 

 

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

 

Author Michael Stack, Principal, 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 & lead trainer of Amaxx Workers’ Comp Training Center. .

 

Contact: mstack@reduceyourworkerscomp.com.

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

Live Stream WC Training: http://workerscompclub.com/livestreamtraining

 

©2017 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.

CMS Provides Another Piece of the Puzzle on Future LMSA Policy

While the Centers for Medicare and Medicaid Services (CMS) has yet to formally issue a policy regarding review of Liability Medicare Set-Asides (LMSAs), since a June 2016 announcement that it was considering expanding the WC MSA review process to liability and no-fault, CMS has nonetheless provided pieces of the puzzle which will ultimately make up a liability and no fault MSA review process. The most recent piece of the puzzle is an announcement by CMS that effective 10/1/2017, no Medicare payments are to be made to medical providers where a Liability Medicare Set-Aside (LMSA) or No-Fault Medicare Set-Aside (NFMSA) exists.

 

 

Directive To Deny Payment For Care Covered Under LMSA or NFMSA

 

The announcement comes via the issuance of a CMS MLN Matters article directed to physicians and other medical providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. It directs these MACs to deny payment for medical care that is covered under an LMSA or NFMSA as identified in the Common Working File (CWF).

 

To clear up some of these technical terms, MACs process Medicare Part A and B payments to medical providers on behalf of Medicare. A Common Working File (CWF) is maintained by the CMS Benefits Coordination and Recovery Center (BCRC) and contains information on a particular claimant’s Medicare eligibility and, importantly, when Medicare should be considered secondary such that payment to a medical provider should be denied and directed instead to the primary plan.

 

BCRC presently keeps records of all WCMSAs that have been approved by CMS and funded through settlement (This is why CMS requires final settlement documents be submitted to BCRC post-settlement). The WCMSA funding information is placed in the CWF so that the MACs deny payment for medical care associated with the WCMSA until the WCMSA is exhausted. This directive from CMS makes this same process applicable to LMSAs and NFMSAs.

 

 

How Can Medicare Deny Payment Based on Processes That Don’t Exist?

 

In response to this announcement, you would be correct in asking, how can CMS deny payment for medical care based upon an LMSA an NFMSA process that does not yet exist? Putting aside that some CMS Regional Offices have reviewed and approved LMSAs at their own discretion for quite some time, this does pose a very good question. CMS responds as follows:

 

CMS will establish two (2) new set-aside processes: a Liability Medicare Set-aside Arrangement (LMSA), and a No-Fault Medicare Set-aside Arrangement (NFMSA).

 

 

New Set-Aside Process Will Be Put In Place At Future Date

 

So CMS readily admits the new set-aside processes will be put in place at some point in the future. Such future date has already been tentatively set based upon CMS’s release, in December 2016, of its request for proposals for the new Workers Compensation Review Contractor which includes an optional provision to expand reviews to LMSAs and NFMSAs effective July 2018 (See prior blog post: CMS MSA Review Expansion to Liability Planned for 2018). Consequently, this directive to the MACs is implementing medical payment processing changes which will be required to be place once the LMSA/NFMSA review process is made available.

 

It is important to keep in mind that CMS has yet to release any guidance on such an expansion of the WCMSA review process to liability and no-fault and particularly how such a process would differ from that created for WC. Also note that CMS does not state that effective 10/1/2017 the MACs are to deny payment for all post-liability settlement injury-related medical care, rather, they are to “deny payment for items or services that should be paid from an LMSA or NFMSA fund.” The funds must exist for denial to occur. Accordingly, over 2017, as more pieces of the puzzle come together on CMS’s Liability and No-Fault MSA review policy, Tower MSA will provide further interpretation and guidance on what will be one of the most significant developments in MSAs since CMS formalized the WC MSA review process in 2001.

 

 

 

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

 

Professional Development Resource

Learn How to Reduce Workers Comp Costs 20% to 50%"Workers Compensation Management Program: Reduce Costs 20% to 50%"
Lower your workers compensation expense by using the
guidebook from Advisen and the Workers Comp Resource Center.
Perfect for promotional distribution by brokers and agents!
Learn More

Please don't print this Website

Unnecessary printing not only means unnecessary cost of paper and inks, but also avoidable environmental impact on producing and shipping these supplies. Reducing printing can make a small but a significant impact.

Instead use the PDF download option, provided on the page you tried to print.

Powered by "Unprintable Blog" for Wordpress - www.greencp.de