A thoughtful and critical review of your Medicare Secondary Payer (MSP) compliance program is a great exercise to perform annually. Consider these questions and metrics:
Questions & Metrics to Assess Work Comp MSA Cost Drivers:
- What percentage of your Medicare Set-Aside (MSA) submissions are accepted?
- Can you identify the biggest cost drivers in your MSAs?
- What percentage of your CMS approved MSAs include opioids?
- What percentage of your approved MSAs include any pharmaceuticals?
- What is the average cost of prescription drugs on MSAs?
- Do you understand why CMS approves/denies MSA proposals?
- Are you overfunding/underfunding MSAs? How do you know?
- Do you know what documentation you need for approval of changes in medical treatment or pharmaceuticals?
If you were not able to confidently answer the questions above it might be time to make some changes to your MSP compliance program. Some claims and risk managers put together a program, let it run and hope for the best. Instead, using data analytics and continuously tracking outcomes and other performance indicators can significantly improve the process of preparing and submitting MSAs to the Centers for Medicare and Medicaid Services (CMS) — especially, where pharmaceuticals are concerned.
MSP Through the Years
It’s been approximately 15 years since the government ramped up its efforts to ensure Medicare doesn’t pay for medical services that should be funded by some other entity, including the workers’ compensation system. At the time, organizations scrambled for ways to develop MSAs that would be approved by CMS.
The process for CMS approvals has evolved over the years. What was a fairly complicated system, to begin with, has turned into an extremely intricate series of steps that can befuddle even the most competent people in the industry – unless they have the benefit of highly advanced technological solutions combined with strong expertise.
For example, in addition to new regulations from CMS, state statutes and fee schedules are also constantly changing. Failing to keep tabs on them can make the process time consuming, costly and fraught with peril.
In the past 18 months, CMS has taken steps to intensify its efforts further. The agency has put millions of dollars into a new contractor and greatly updated its technology, making the process of identifying mistakes that much quicker and easier. It means anyone trying to stay in compliance with Medicare also needs to improve and upgrade their systems.
What the Metrics Can Tell Us
Most workers’ compensation payers would agree that pharmacy is the biggest cost driver for their MSAs. However, few know the answers to these key metrics:
- What is your current pharmacy spend on MSAs?
- What percentage of your CMS-approved MSAs include opioids?
- What percentage of MSAs are approved with or without drugs?
- What is the average cost of prescription drugs on your MSAs?
With medications comprising such a tremendous portion of MSA costs, it’s vital to have a clear understanding of the issue. This can only be accomplished by focusing on the metrics. By analyzing the data on opioids as well as other pharmaceuticals in terms of your MSAs that are approved, you can then begin to fully manage these costs.
Optimizing MSA Outcomes
Whether working with an MSA vendor or doing Medicare compliance on your own, several strategies are a must for success.
- Identify metrics that drive the results you want to see, particularly where medications are concerned.
- Measure your performance and modify processes, workflow, and technology to improve it. For example, look at the percentage of your MSAs with ongoing medical to see how much you have allocated for opioids. If the answer is anything more than zero, go back to the drawing board.
- Examine current CMS performance and the most recent state statutes and fee schedules against CMS’s review methodology as defined in the most recent Workers’ Compensation MSA Reference Guide. If/when there are changes, update your system immediately. Once developed, this should be a simple verification, audit and sign-off process.
- Analyze every CMS response against your internal best practices in MSA allocation, with a focus on pharmaceuticals and opioids. You want to know how you are performing against CMS in such areas as pricing, frequency and life expectancy.
- Leverage Section 111 data to improve the CMS approval rate of MSAs.
To truly effect change in your Medicare compliance program requires examining certain metrics and taking steps to manage them best. For example:
- What is the number of Medicare conditional payment searches and investigations initiated and the success rates for disputes and appeals, including dollars saved?
- What type of clinical interventions have been initiated, what is their success rate and the average dollar amount saved because of them? This strategy can save many thousands of dollars per claim. Investigating each claim with an eye toward medical procedures anticipated and/or pharmaceuticals can yield surprising results. You may find, for example, a doctor is prescribing a medication the injured worker no longer takes or has never taken; so removing that drug from the future medical amount is an easy change.
- What is the percentage of submissions to which CMS has countered with a higher dollar amount? A lower dollar amount? If there is a high percentage of either, you need to understand why there is a trend and how to counteract it.
You want the injured worker to have adequate funds for his lifetime needs related to the injury, but you don’t want to pay unnecessarily high costs. Often the projected expenses are way too high, or the therapy is not within evidence-based medical guidelines.
The best MSA developers can fully assess exposure before the proposal is submitted. They can spot inappropriate or unnecessary treatment and pharmaceuticals AND take steps to curb them such as physician peer-to-peer discussions, for example.
Paying too much for anything does not make sense. But, that’s exactly what happens far too often because many workers’ compensation payers don’t take advantage of advanced technologies in developing MSAs. Using metrics and data analytics and working with an MSA expert can help ensure injured workers get what they need and deserve without payers going overboard.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a 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 .
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