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.
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: email@example.com.
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