Eliminate ‘MSA Fear’ In Upcoming WCI Session in Orlando

msa fearAmong the biggest fears of many people you may know are heights, snakes — and MSAs. Workers’ compensation stakeholders often want to avoid the very idea of Medicare Set-Asides.  Among their concerns are

 

  • Fees for MSA preparation
  • MSA professional administration
  • Cost of the MSA
  • Requirements to obtain additional medical documentation
  • Time involved
  • Submitting the MSA to the Centers for Medicare and Medicaid Services
  • Failed settlements due to rejected MSAs

 

For injured workers, their concerns about MSAs may be the biggest thing keeping them from settling their claims.  The fear of running out of money too soon is often stronger than their dislike of the workers’ compensation system. Knowing they will have to navigate their own healthcare with no support from adjusters and/or case managers can also generate concerns. Finally, there is the uncomfortable prospect of having to administer their own MSA funds, or turning that task over to someone else

 

With so many parties apprehensive about MSAs, it’s no wonder many workers’ compensation claims go unsettled for years.

 

On Aug. 14, a panel of experts will discuss the fear of MSAs and how to overcome them to allow settlements to move forward. The session, Allaying the MSA Fear at the Time of Settlement, takes place during the 74th annual Workers’ Compensation Educational Conference (WCI), Aug. 11 – 14 at the Orlando World Center Marriott.  I’ll have the pleasure of moderating the session.

 

With expertise in MSAs, structured settlements, and professional administration, the speakers include:

 

  • Kris Sallee, Claims Manager-Eastern Region, American Airlines
  • Daniel Anders, Chief Compliance Officer, Tower MSA Partners
  • Marques Torbert, Chief Executive Officer, Ametros
  • Joe Bornstein, Structured Settlement Consultant, Arcadia Settlements Group

 

Using real case studies, the panelists will demonstrate how to approach settlements logistically by using an intervention-driven method to develop MSA allocation, professional administration to protect MSA dollars and support the injured party after the settlement, and a structured settlement to extend the dollars over the person’s lifetime.

 

The speakers will provide practical solutions to ‘MSA fear,’ and show how using each type of expert creates a synergy that allows for a smooth settlement process when an MSA is involved. They will also address the risks of not submitting an MSA for CMS review. And they will take questions from attendees.

 

 

 

Michael Stack - AmaxxAuthor 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 the founder & lead trainer of Amaxx Workers’ Comp Training Center .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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.

Bringing Understanding of MSA Complexities at WCI in Orlando

Understanding of MSA CompliexityMedicare Set-Asides are a pain-in-the-neck nightmare for many workers’ compensation stakeholders. They are expensive, complicated, and seemingly fraught with landmines. One misstep could cost a bundle for you and anyone else involved.

 

Concerns over MSAs result in a plethora of workers’ compensation claims left open – often years after they could have and should have been closed. Payers end up spending far more for ongoing medical than would have been allocated in an MSA, had the case been settled long ago.

 

But there is good news! MSAs don’t have to be ridiculously expensive or complex. Yes, they need to be carefully managed, and they need to be overseen by someone with a deep understanding of the intricacies of the Medicare Secondary Payer Act and the Centers for Medicare and Medicaid Services’ processes. Employers, payers, and others who have a basic insight into MSAs can approach claims settlement realistically, getting long-term claims off their books and helping injured workers to be in the best position to move forward with their lives.

 

A major employer and an MSA expert will take a deep dive into the issue during the 74th annual Workers’ Compensation Educational Conference (WCI), Aug. 11 – 14 at the Orlando World Center Marriott. Their focus will be on ways to measure and manage MSA costs. The session, Optimizing Settlement Outcomes by Measuring and Managing MSA Costs takes place Wed., Aug. 14, at 10:00 a.m. I’ll have the pleasure of moderating the session.

 

 

Measuring

 

The first step in assuring accurate future medical costs is to know what is in them. For example, do you know:

 

  • How many of your MSAs contain prescription drugs, the most commonly cited reason for high MSA costs?
  • How many contain prescription medications?
  • Your average CMS approved MSA amount?
  • Your trend lines year over year for your MSA program?

 

Attorney Dan Anders, the chief compliance officer for Tower MSA Partners, and Kris Sallee, claims manager-Eastern Region for American Airlines will provide metrics that will help you determine your MSA program success. Anders will show national standards, while Sallee will offer her company’s metrics to better understand how to measure your own program. Most importantly, the speakers will explain what the metrics mean and how they can be used to improve your MSA program.

 

 

Cost Management

 

Once the metrics are understood, it’s time to get down to the business of actually managing the costs of an MSA. The same types of best practices used for handling claims also come into play when developing MSAs, such as clinical interventions. For example, reducing unnecessary treatments and medications during the claims handling process will reduce the cost of the MSA.

 

Certain treatments, such as spinal cord stimulators and revision surgeries are most likely to increase MSA costs – and are often unnecessary. Likewise, certain medications may no longer be needed for the injured worker. Or there may be instances where a generic medication can be substituted for a brand name, either currently or in the near-term future when a patent for a particular medication expires.

 

The speakers will show attendees how to draft an MSA with an eye toward cost and frequency, as well as identifying opportunities to limit the MSA before sending it to CMS. Submitting the MSA can be tricky, and the panelists will address the necessary steps, especially the re-review process, when a dispute can be raised.

 

Finally, the speakers will allocate time for questions about all things MSA.

 

 

Michael Stack - AmaxxAuthor 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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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: More than $1.5 Million in Savings Through Generic Substitutes

Generic drugs in workers' compensationThe latest Drug Trend Report from myMatrixx once again showed a substantial cost difference between brand-name and generic drugs. In fact, while the costs of brand name drugs are increasing, prices for generics are steadily decreasing. Unfortunately, some workers’ compensation stakeholders overlook this issue when preparing Medicare Set-asides.

 

Medications prescribed for the injured worker are expected to be included in the MSA to gain approval by the Centers for Medicare and Medicaid Services. There are exceptions; however; such as when it can be demonstrated the injured worker is no longer taking the medication. But switching from brand-name to generic medications is one of the most efficient and effective ways to reduce costs.

 

 

Generics vs. Brand-Names

 

Some people are concerned that generic drugs are of lower quality than brand-name medications. The Food and Drug Administration stipulates that all generic drugs must be equivalent to their brand-name counterparts. Additional FDA requirements include:

 

  • That generic drugs have the same active ingredient, strength, dosage form, and route of administration as the brand-name drug.
  • The generic manufacturer must prove its drug is the same (bioequivalent) as the brand-name drug.
  • All manufacturing, packaging, and testing sites must pass the same quality standards as those of brand-name drugs.
  • Any generic modeled after a single, brand name drug must perform approximately the same in the body as the brand name drug.

 

The FDA also points out that many generic drugs are made in the same manufacturing plants as brand-name drugs.

 

Are there differences between generics and brand name drugs? Yes, but as the FDA points out: “There will always be a slight, but not medically important, level of natural variability just as there is for one batch of brand name drug compared to the next batch of brand name product. This amount of difference would be expected and acceptable, whether for one batch of brand name drug tested against another batch of the same brand or for a generic tested against a brand name drug.”

 

Generic drugs are cheaper than brand-names because the manufacturer making the generic version does not have to go through costly clinical trials that new drugs do. Also, they don’t generally pay to advertise, market or promote the drug, since the brand-name maker has already established the drug in the marketplace. The competition created by multiple manufacturers developing a generic version of a brand-name medication further drives down the price of the medication.

 

The only reason for any patient to use a brand-name over a generic medication is if the generic drug causes unusual side effects to a particular person or, in rare cases, is less effective. In the vast majority of cases, patients do just as well with generic medications as with their brand-name counterparts.

 

The biggest difference between generic and brand name medications is the price. A case study of a recent MSA is a dramatic example of this.

 

 

Case Study (Provided by Tower MSA Partners): More than $1.5 Million in Savings Through Generic Substitutes

 

An injured worker who had been diagnosed with Post Traumatic Stress Disorder, anxiety and mood disorders was taking a variety of medications to treat his conditions. Among the more costly drugs were Wellbutrin, Klonopin, Rozerem, and Neurontin — all brand-name medications.

 

When discussions about settling the claim began, the initial MSA included $1,657,022 for medications and $30,058 for future medicals.

 

Total MSA Exposure — $1,687,081.

 

 

Solution

 

After identifying the brand-name medications as the key cost drivers in the initial MSA allocation, Tower recommended working with the injured worker’s attorney and the treating physician to switch to generic substitutes. The switch from brands-to-generics took several months to complete, to ensure the effectiveness of each.

 

When the conversion was completed, a physician’s statement was obtained confirming the switch from brand to generic, as well as an updated prescription history documenting ongoing generic use. Tower promptly submitted an MSA with an allocation of $112,572.

 

Results

 

CMS approved the MSA within eight days, allowing the parties to settle. The switch from brand-name to generic medications resulted in savings of $1,574,509 — and assured the injured worker would have enough funds for his future medicals and medications.

 

Conclusion

 

Developing and getting FDA approval for a medication is a long, complicated process. Drug manufacturers charge for a medication based on their expenses for creating and bringing the drug to market. Once the patent expires for a particular medication, other manufacturers are free to produce the same drug — as long as it meets the FDA standards for generics; i.e., it is the same drug.

 

The cost difference between generic and brand-name medications continues to grow further apart. By carefully looking at the medications prescribed for an injured worker and working with various stakeholders involved, an appropriate, cost-effective MSA can be created.

 

 

 

Michael Stack - AmaxxAuthor 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.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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: $270,917 in MSA Savings Through Physician Follow-up

Reduce your workers' comp case studyDeveloping a Medicare Set-Aside is not only a time-consuming and arduous process, but can also be unnecessarily expensive. There are many instances where tremendous sums of money are included in an MSA just because stakeholders were not diligent in analyzing what was included.

 

A case in point was a recent situation in which a medication the injured worker had taken only one time was set to be part of his lifetime medications in the MSA. Had this seemingly simple oversight not been flagged, it would have driven up the cost of the MSA by hundreds of thousands of dollars!

 

We hear all too often about injured workers who, unfortunately, fall through the cracks in the workers’ compensation system and are not appropriately cared for. While these represent only a small minority of cases, they generate headlines. Equally disturbing are stories of injured workers who’ve settled their cases and soon after find themselves out of money with no hope of paying for their future medical expenses, let alone moving on with their lives.

 

The goal of developing an MSA is to identify as accurately as possible the total cost that will be incurred during the injured worker’s life. The amount needs to include all expenses related only to the specific injury, as well as other treatments that may be needed later on.

 

Either party – injured worker or employer/payer – can wind up on the losing end of a settlement if it is not done correctly. This is why it is so important for all parties to carefully review the medications, procedures, and costs involved before signing off on an MSA.

 

 

Case Study (Provided by Tower MSA Partners): $270,917 in Savings from Physician Follow-up

 

An injured worker had been diagnosed with a variety of conditions stemming from a workplace injury, including depression, anxiety, complex regional pain syndrome and bilateral hand/arm pain with radiation to his right shoulder and neck. He was ready to settle his claim and leave the workers’ compensation system.

 

Among the six RXs included in the MSA projection was Nucynta 50mg. This opioid is meant to be a short-term treatment for moderate to severe pain. Not only is it highly addictive, but also extremely expensive. It comprised $245,721 of the MSA amount.

 

The worker had, understandably been treated by several physicians in the year before he agreed to settle. But the medical records were less than complete.

 

Total MSA Exposure — $326,925.

 

 

Solution:

 

With so many physicians involved, Tower’s physician follow-up team first obtained statements from each of the six providers involved in the worker’s treatment. They confirmed the last dates of services and whether medications had been continued or not. If they were, the name of the drug, dosage, and frequency for each was requested.

 

The physician who had prescribed Nucynta confirmed it was a one-time fill that was subsequently discontinued. The team identified several additional discrepancies in the statements from the physicians and had the physicians document the medical records with a revised medication list that reflected what the injured worker was actually taking and expected to need going forward.

 

 

Results:

 

Removing Nucynta from the medication list reduced the projected amount of the MSA by more than $245,000. An additional $81, 204 was also eliminated, based on the physicians’ statements

 

The MSA went from $326,925 to $56,008 — a savings of $270,917 and, with no negative impact on the injured worker!

 

 

Conclusion:

 

While the particular medication involved in this case was on the high-end of errors, the situation is all too familiar. Stakeholders often take information about current and future medications and treatments at face value, without delving into what is behind the numbers.

 

This case is typical in that a variety of physicians were involved, their records in many cases were incomplete, and there were medications included that had no bearing on the injured worker’s current, let alone future status.

 

Creating accurate MSAs takes time and skill. Those who undertake them need to ask questions and obtain all relevant information in order to come up with an amount that is fair to all sides.

 

 

 

 

Michael Stack - AmaxxAuthor 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.

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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.

Steps to Optimize Medicare Set Asides Before — and After — Settlement

Optimize MSAs Most workers’ compensation practitioners agree: Medicare Set-Asides can be a pain in the neck.  It takes time, resources and skill to create an MSA.  In addition, any snag could result in a loss of money — for the injured worker as well as other parties involved.

 

The myriad of moving parts and high chance for error, along with getting approval from the Centers for Medicare and Medicaid Services are the reasons a specialized industry has arisen around MSAs as well as other components to Medicare Secondary Payer compliance.  By understanding such things as when, how, and where to get an appropriate MSA and ensuring post-settlement assistance is available for reporting and follow-through, stakeholders can settle more claims and feel confident they are doing the right thing for injured workers and other parties involved.

 

 

MSA Realities

 

Here are a few sobering, post-settlement, realities from a professional administrator that demonstrate why MSAs cause angst to so many:

 

  1. There were 51% more phone calls from Medicare on MSA administration in 2018, compared to 2017
  2. Medicare inquired on virtually 100 percent of lump sum MSA exhaustions
  3. Medicare checked in on 1-out-of-every-3 structured settlement exhaustions
  4. CMS is adding more technology and getting smarter about compliance every year, especially with the post-settlement administration of the MSA.

 

In other words, don’t expect the government to ease up on ensuring Medicare’s status as the secondary payer in workers’ compensation cases anytime soon. Quite the opposite is happening as Medicare becomes more intent on not only ensuring the MSA was accurately put together but that the funds are spent appropriately.

 

 

MSA Q&As

 

Here are appropriate questions you need to ask and what to look for.

 

 

When is the right time to obtain an MSA?

 

When an injured worker has reached maximum medical improvement. Someone who is about to have or just had surgery, or is changing medical providers is not an appropriate candidate because his medical situation is likely to change. The injured worker should have his medications and treatment stabilized.

 

 

How can MSA amounts be deemed sufficient for the injured worker but not excessive?

 

You want to make sure the injured worker has the funds he needs to live out a fulfilling life, but don’t want to spend unnecessary dollars. This requires working with an MSA partner willing to take a deep look into the injured worker’s situation, now and in the future. There may be some projected treatments and/or medications that are inappropriate and unnecessary. Things to consider are:

 

  • Generic alternatives to medications
  • Potential overuse of opioids
  • Inconsistencies between medical records and prescription drug history
  • Whether authorized medications are still being prescribed or used
  • Medications that are unrelated to the occupational injury
  • Planned surgery that the injured worker does not want or need
  • Estimated costs for surgeries and other treatments that may be unrealistic
  • Frequency of physician visits
  • Rated age/life expectancy
  • Evidence-based medicine; to ensure it is being followed

 

 

What is clinical intervention and why is it important?

 

Identifying and clarifying these and other issues takes leg work. The MSA vendor must be willing and able to work with treating physicians and others to get the correct answers, as these are key to both saving money and protecting the injured worker.

 

This may include

 

  1. Physician follow-up
  2. Clinical oversight
  3. Peer-to-peer review, where another physician is brought in to work with the treating physician
  4. Addressing inappropriate care — another area where peer review is advantageous

 

There are situations, for example, when a particular medication is listed as being current but is no longer being prescribed. The solution is to have both the injured worker and the treating physician write statements specifying the date the medication ceased to be prescribed or used.

 

Another typical example is when a treating physician had discussed a specific treatment — such as a spinal cord stimulator, but later determined it was not necessary. The cost of a spinal cord stimulator can be in excess of $150,000. In that case, the MSA partner should seek a statement from the treating physician confirming the treatment is no longer necessary or reasonable.

 

 

What are indications of an effective MSA partner?

 

When considering organizations for partnerships, facts and figures tell the story. Some to look for include:

 

  • CMS MSA approval rate
  • Percentage of MSAs with prescription medications, especially opioids
  • Percentage of cases settled
  • Savings from clinical interventions
  • Rate of development letters
  • Average MSA approval amount

 

“These metrics determine the success or failure of an MSA program in limiting allocation amounts and facilitating settlement,” says Dan Anders, Chief Compliance Office of Tower MSA Partners.  “Your MSA partner should be using these key performance indicators to drive the outcomes you want to see.”

 

 

Post-Settlement MSA Support

 

Just because the MSA has been developed and approved by CMS and the claim settled, does not mean things cannot still go wrong. Complying with CMS requirements — including reporting duties — is crucial. That’s why it’s just as important to have a post-settlement strategy set up before the claim is settled. If the injured worker unintentionally fails to adhere to CMS guidelines and the money runs out —

 

  • They jeopardize their future Medicare benefits
  • They may be forced to reimburse all the money that was misspent, up to the full settlement amount
  • Their attorney(s) and/or others (including the adjuster/payer) may also be pulled back into the case, which can cause unnecessary burdens and work on everyone involved

 

Those in the best position to ensure things go smoothly after the settlement are professional administrators. These are neutral, third-party experts who handle all compliance and annual reporting for MSAs. Additionally, professional administrators establish a bank account for the injured worker’s future medical care and act as custodian — receiving the medical bills and paying them on behalf of the injured worker.

 

“There are a lot of things that happen in the settlement process that could confuse an injured worker,” said Marques Torbert, CEO of the leading professional administration company, Ametros. “Injured workers are worried about getting better. A professional administrator makes sure the injured worker has a support system and access to savings and support post-settlement while helping to keep them in compliance.”

 

A professional administrator should have extensive physician and pharmaceutical networks, which results in cost savings for the injured worker and extends the life of the MSA. Top-notch professional administrators demonstrate significant cost savings for injured workers while also protecting Medicare’s interests by maintaining the viability of the MSAs account over those workers’ lifetimes

 

Average Savings From Top Professional Administrator

 

  1. 63% on provider bills
  2. 28% on other medical expenses
  3. 50% with bill review adjustments

 

Many advocates for injured workers are finding that bringing in professional administrators during the settlement process can be extremely valuable. Because they are neutral third parties, they can serve as mediators for competing interests; such as carriers, and plaintiff and defense attorneys.

 

“Bridging the gap to settlement can sometimes be difficult,” says Torbert. “At the end of the day you have several stakeholders at the table, the only party that stays with the injured worker well after the settlement is the professional administrator. Being able to show the injured worker that they will be taken care of can help all parties come to a resolution.”

 

The benefits of professional administrators are such that CMS itself last year “highly recommended” injured workers consider using them for MSA administration.

 

 

Conclusion

 

Injured workers who have been in the workers’ compensation system for long periods are often hesitant to settle their claims due to fears of running out of money. An improperly developed or utilized MSA is one of the main reasons that fear can come to fruition. Having the right partners involved brings peace of mind to injured workers, as well as all parties involved in settlement.

 

 

 

Michael Stack - AmaxxAuthor 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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2019 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.

12 Questions and Metrics to Assess Work Comp MSA Cost Drivers

12 Questions and Metrics to Assess Work Comp MSA Cost Drivers 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.

 

  1. Identify metrics that drive the results you want to see, particularly where medications are concerned.
  2. 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.
  3. 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.
  4. 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.
  5. 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:

 

  1. What is the number of Medicare conditional payment searches and investigations initiated and the success rates for disputes and appeals, including dollars saved?
  2. 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.
  3. 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.

 

 

Conclusion

 

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.

 

 

 

Michael Stack - AmaxxAuthor 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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 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.

6 Steps to Keep Liability Settlements Out of Medicare’s Crosshairs

Keep Liability Settlements Out of Medicare’s CrosshairsNo one likes to pay for items that are not their responsibility. This statement is true of the federal government in the workers’ compensation industry as the feds have exerted control over settlements involving injured workers who are or will soon be covered by Medicare.  An entire cottage industry has sprung up comprised of experts who develop Medicare Set-Asides (MSAs) and ensure Medicare’s interests are considered before a workers’ compensation settlement is finalized.

 

As the Medicare Set-Aside industry has grown and matured in workers’ compensation, a similar approach is now being considered with liability settlements. The law on the books for decades clearly says that Medicare is supposed to be a secondary payer in such settlements. Lately, there have been clear indications the Centers for Medicare and Medicaid Services (CMS) plans to take action on this soon. How it will ultimately shake out is up for debate. In the meantime, payers should at least be aware of what is happening and take steps to prepare.

 

 

The Issue

 

“The extent to which settling parties must consider Medicare’s interests in medicals in a liability settlement continues to be unclear.” Thus begins a new white paper discussing the issue and what can be done. Written and published by Tower MSA Partners, Navigating Through the Fog: Medicare, Future Medicals & Liability Settlements reviews the workers’ compensation experience with CMS, outlines likely scenarios for liability settlements, and provides tips for payers.

 

Liability insurance coverage protects the policyholder or self-insured entity against claims based on negligence, inappropriate action, or inaction that results in bodily injury or property damage.

 

Examples include

 

  • Homeowners’ liability insurance
  • Automobile liability insurance
  • Product liability insurance
  • Malpractice liability insurance
  • Uninsured motorist liability insurance
  • Underinsured motorist liability insurance

 

Medicare beneficiaries must notify Medicare when a liability claim is made against a party with liability insurance and the liability carrier must report to Medicare when it settles a claim with a Medicare beneficiary. When there is a settlement, Medicare expects reimbursement for any payments it covered that should have been paid out of the settlement.

 

The settlement becomes more complicated when there are future medical costs for the specific injury. If Medicare is billed, it may seek reimbursement. In those situations, Medicare’s interests should be taken into account, and a liability MSA may be advisable.

 

 

Medicare Has Not Yet Established Framework for Liability MSAs

 

Unlike the process for workers’ compensation MSAs, Medicare has not established a framework for reviewing LMSAs or provided any guidance on the issue. Instead, any CMS reviews for proposed LMSAs that do occur are done on a case-by-case basis and only by some regional offices.

 

The good news is that, so far at least, there are no known incidents of CMS denying payment or seeking reimbursement for injury-related medical care after a liability settlement. Tower MSA Partners anticipates action from CMS within the next two years. When that happens, according to the white paper, CMS will need to address issues including:

 

  • Review thresholds
  • Allocation of the MSA based upon a compromise formula
  • Documentation required to submit to CMS with an LMSA proposal
  • Whether the LMSA review will occur pre- or post-settlement
  • Timeline for LMSA policy implementation
  • Multiple defendants and mass tort settlements
  • Pricing of medical in an LMSA (usual and customary vs. Medicare rates)

 

Other factors that come into play with liability settlements include policy limits, statutory tort caps, negligence rules, pre-existing conditions, case law and other issues that may result in a settlement for less than the full value of the claim.

 

 

What to Do

 

With things up in the air regarding liability settlements, one question is whether a claim for reimbursement could extend to the claimant and the primary plan, as well as the claimant’s attorney. Right now, it is uncertain.

 

Despite the vagueness of the issue, Towers suggests payers take the following actions to protect themselves and claimants.

 

  1. Identify whether the claimant is a Medicare beneficiary or has a reasonable expectation of Medicare eligibility within 30 months.
  2. If Medicare eligibility is or soon will come into play, evaluate the necessity of future injury-related medical care. Is future medical care claimed in the settlement demand or alleged in the pleadings?
  3. If there is a necessity of future injury-related medical care, will this burden likely be shifted to Medicare? For example, does the claimant have a source other than Medicare to pay future injury-related medical care; e., group health plan, which will likely cover future injury-related medical?
  4. If Medicare is the likely source of future injury-related medical care, consider whether there are sufficient settlement funds to allocate a portion to fully fund future medicals. If so, then consider an LMSA as part of the settlement. If there are insufficient funds to fully fund future medicals, then consider an apportionment of the future medical allocation in relation to other damages allocated in the settlement.
  5. Document the file and settlement/release in regard to steps taken to consider Medicare’s interest:

 

– If an LMSA or other type of allocation for future medical has been included in the settlement, ensure the plaintiff is aware of his or her responsibilities in utilizing those funds for future medical expenses.

– If the LMSA has been apportioned, document the reasons why such a reduction was taken.

– If no LMSA or allocation for future medical has been included in the settlement, then ensure the plaintiff is aware of the potential implications for future payments by Medicare for injury-related medical care.

– Document why no such allocation has been included in the settlement/release.

 

  1. Besides the future medical considerations, remember as well to investigate and resolve Medicare conditional payments, including payments made through Part C Medicare Advantage Plans.

 

 

Conclusion

 

Medicare may begin denying payment for claims if it determines that payment should have been made through a liability insurance policy or another primary payer. Such a change would likely delay liability settlements. Therefore, it is imperative to work with an experienced settlement planning professional, as failure to comply with MSP provisions can result in severe penalties.

 

 

Michael Stack - AmaxxAuthor 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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 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: $951,189 in Savings Through MSA Optimization

Reduce your workers' comp case studyAttention to detail cannot be overstressed when it comes to finalizing Medicare Set-Asides. The Centers for Medicare and Medicaid Services is very specific regarding what can and should be included to gain its approval. Beyond that, those setting up the MSA need an in-depth understanding of the rules to ensure the injured worker gets what he needs while keeping costs in check.

 

The CMS rules for MSAs are intricate and laced with nuances. Additionally, the agency often issues changes intended to ease the process. That means those tasked with creating the MSA must have a clear understanding of the latest iteration of the rules.

 

 

MSAs

 

An MSA is a portion of a total workers’ compensation settlement designed to cover expenses for all future medical expenses related to the workplace injury that would otherwise be reimbursable by Medicare. The goal is to identify as accurately as possible the total cost that will be incurred during the injured worker’s life.

 

CMS approval is not a legal requirement for an MSA. However, the potential financial repercussions for providing an inadequate MSA are such that many industry stakeholders find it wise to submit proposed MSAs to the agency.

 

Estimating the future medical costs takes enormous skill. For example, the final amount takes into account only the expenses related to the specific injury. Also, it needs to include things such as durable medical equipment that, while not needed presently, may be necessary in the future. Surgeries and other recommended medical treatments should also be included.

 

At the same time, the MSA should not include treatments or medications that are either not related to the injury or are not currently being used, or expected to be used by the injured worker. Unfortunately, when treatment recommendations are not clearly stated in the medical records, the concern that CMS may return a ‘counter higher’ response can lead many to overfund MSAs — especially, in the case of medications.

 

 

 

Case Study (Provided by Tower MSA Partners): $951,189 in Savings from MSA Optimization

 

 

CMS guidelines stipulate that medications listed as ‘active’ by the treating physician should be included in the MSA — even if the injured worker is not taking them.

 

 

Challenge

 

Pennsaid (Diclofenac Sodium) is a topical, nonsteroidal anti-inflammatory drug used to treat pain. The injured worker received a sample of the medication and a prescription of Pennsaid 1.5 percent for low back pain. However, the medication did not effectively manage the pain, so the injured worker never filled the prescription. The claims adjuster was unaware of the prescription since it had been provided as a sample dose followed by a paper prescription.

 

Total MSA Exposure — $970,355

 

Solution

 

Tower MSA’s physician follow-up team worked with the assigned nurse to make the treating physician aware that the injured worker was not filling the prescription. The doctor agreed to discontinue the medication and replace it with an oral version of Diclofenac. He also offered to prescribe Nabumetone, another nonsteroidal anti-inflammatory medication used to treat pain. However, the injured worker also did not fill that prescription.

 

A letter was sent by the physician to confirm discontinuation of the ‘active’ medication. It included the following language:

 

“I discontinued [the injured worker’s] Pennsaid 1.5%. He was offered Nabumetone, but the patient declined this medication.”

 

The pharmacy benefit manager blocked both medications to prevent the possibility of either being reintroduced. The letter from the physician was appended to the MSA, and both Pennsaid and Nabumetone were removed from the prescription drug portion of the allocation.

 

 

Results

 

In its review of the MSA, CMS accepted Tower’s physician letter as evidence of the discontinuation of both drugs and approved the MSA in full.

 

The removal of Pennsaid and Nabumetone drastically reduced the MSA allocation:

 

Initial MSA Allocation$970,355
Savings from Removal of Pennsaid & Nabumetone:$951,189
 

Final MSA:

 

$  19,166

 

Conclusion

 

Injured workers should not have to worry about paying for future medical expenses related to their workplace injuries after they settle their workers’ compensation claims. At the same time, overpaying an MSA for unused and unnecessary services and medications serves no one’s best interests. It’s important to use experts to ensure the appropriate funding amount is allocated.

 

 

Author Michael Stack, CEO Amaxx LLC. He is an Michael Stack - Amaxxexpert 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 .

Contact: mstack@reduceyourworkerscomp.com.

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

©2018 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.

Proposed PAID Act Intends to ID Medicare Part C, Part D and Medicaid Enrollees for Insurers

Proposed PAID Act Intends to ID Medicare Part C, Part D and Medicaid Enrollees for InsurersOn 5/18/2018, the Provide Accurate Information Directly (PAID) Act was introduced in Congress for the purpose of allowing settling parties an easy method to identify if a claimant is enrolled in a Part C or D plan or Medicaid.  The bill, H.R. 5881, sponsored by U.S. Rep. Gus Bilirakis R-Fla and U.S. Rep. Ron Kind, D-Wisc, requires the Centers for Medicare and Medicaid Services (CMS) to share information on not only whether a claimant is a Medicare beneficiary, but also whether the claimant is enrolled in a Part C Medicare Advantage (MA) Plan, Part D Prescription Drug Plan or Medicaid.  It also requires CMS to provide the identity of the MA or Part D Plan or state Medicaid program in which the claimant is or was enrolled.

 

 

Stepped-Up Efforts to Seek Reimbursement From Settling Parties

 

The catalyst for this legislation comes from stepped up efforts by these various plans and programs, especially by MA Plans, to seek reimbursement from settling parties. MA Plans have largely prevailed against insurance carriers in seeking reimbursement under the Medicare Secondary Payer Act which has led to a heightened awareness of the potential for such claims and the need to identify claimants enrolled in such plans and programs prior to settlement.

 

While liability and no-fault carriers and workers’ compensation plans are now on notice of the potential for such reimbursement claims, there presently exists no universal method to identify a claimant’s enrollment status, short of asking the claimant.  Accordingly, the bill provides a solution by requiring CMS to share such enrollment information.

 

 

Enrollment Information Shared Through Mandatory Insurer Reporting

 

A review of the bill shows the enrollment information would be shared through the Section 111 Mandatory Insurer Reporting query process.  In short, along with identification of whether a claimant is a Medicare beneficiary, the query response would also provide whether the claimant is or has been enrolled in a MA or Part D Plan or a state Medicaid program for the past three years and the name of the plan or program.  The insurance carrier or self-insured entity would then be able to readily contact the Part C or D plan or Medicaid program to resolve any claim for reimbursement.

 

The bill was referred to the Committee on Ways and Means and the Committee on Energy and Commerce for further action.  Tower MSA Partners will provide updates on the legislation when warranted.

 

 

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

8 Steps to Obtain Faster, More Accurate Medicare Set-Asides

8 Steps to Obtain Faster, More Accurate Medicare Set-AsidesMedicare Set-asides can take time, money and valuable resources in the claim settlement process. Partnering with experts makes both financial and logistical sense to get your claims settled that much faster, and for the lowest cost.

 

Taking a proactive approach and truly engaging with your MSP vendor will help limit the costs and time to create the best possible MSA.

 

 

Action Steps

 

Strengthening your relationship with your MSP provider requires you to become involved, rather than taking a back seat and expecting the vendor to do it all. Here are actions that will help:

 

 

  1. Provide Complete Information

 

An accurate, defensible MSA report is dependent on the availability of all pertinent information and documentation. You don’t want to delay the process by having to revise the report because of missing information. While the MSA company may be able to access your claim system for relevant records, there may be older records and legal documents in a different system. At the time of referral the following information should be provided:

 

  • Complete referral form
  • Claim payment history
  • Two years of medical records for each
  • Accepted and denied body parts
  • Multiple dates of injury settling
  • Court orders and rulings
  • Depositions

 

 

  1. Read and Heed the Report

 

In addition to a projected dollar amount, the MSA report should include the basis for the number along with recommendations on ways to reduce the allocation and streamline the process. Failing to read through the report and follow the recommendations is wasting your money. For example, there may be suggestions to

 

  • Clarify ongoing medication use
  • Address open-ended treatment
  • Implement an action plan to reduce high opioid or other medication use

 

The vendor may have services that can address these and other issues that will better ensure CMS approval. Also, the report may include unintentional oversights or a misinterpretation of the records. Since you know the details of the claim better, it makes sense to read through the report and question anything that you don’t understand.

 

 

  1. Allow for Intervention

 

Missing medical reports, open-ended medication recommendations, and inconsistent physician statements are among the many hurdles that can increase the allocation or stall the approval process. The MSA vendor should provide an intervention plan to address any such issues that arise before the MSA report is completed and submitted to CMS. You should authorize the company to move forward with the plan and to meet with any attorneys involved if necessary.

 

 

  1. Work with the Compliance Team

 

A couple of questions are best left to attorneys, such as whether an MSA is even necessary and, if so, how state statutes, regulations or case law may affect the preparation and submission of the MSA. MSP vendors typically work with attorneys who are experts in MSP compliance. They can show you various tactics to limit the allocation amount. To do so, you need to provide the vendor with information on accepted and denied body parts along with relevant court orders, rulings or depositions.

 

 

  1. Agree to Escalation

 

A claims professional who neglects to respond to a recommendation from the vendor can create problems getting CMS approval. Conversely, the MSA vendor’s front-line personnel may not be giving you the information you need. Both you and the vendor should agree to have an escalation process in place. This will allow the vendor to bring the recommendation to a supervisor or manager, and lets you talk with a key contact at the vendor’s office to get a complete picture of any issues that must be addressed.

 

  1. Task Vendor as Gatekeeper

 

If your organization has many legacy or other claims that have been open for a while, you may want to conduct a settlement initiative. This typically involves many parties; such as defense attorneys, structured settlement brokers, professional administrator and a medical case manager. Have the MSA vendor act as the gatekeeper for this, by coordinating MSA development, clinical intervention, and CMS submission. That frees up the claims handler and defense attorney to focus on settlement negotiations and finalization.

 

 

  1. Include the Vendor in Finalization

 

The settlement terms must be consistent with CMS guidelines, including the proper inclusion of the MSA and defining Medicare conditional payment resolution. Also, CMS requires the MSA company to submit final, court-approved, settlement documents to make the approved MSA effective. Your defense attorney should, therefore, work with the MSP compliance team to avoid any problems later.

 

 

  1. Monitor Performance Metrics

 

You want to make sure your partnership with the MSA vendor continues to be successful and correct any areas that need improvement. The vendor should be able to provide performance metrics, such as

 

  • The number of MSA referrals
  • The turnaround time to write the MSA report
  • The CMS approval rate
  • Percentage of MSAs with prescription medications
  • Cost savings as a result of interventions
  • Percentage of MSAs with Development Letters from CMS

 

 

Conclusion

 

MSAs are complicated and can be expensive and time-consuming. Partnering with the right experts and staying involved with them can get you to a less costly settlement sooner.

 

 

Michael Stack - AmaxxAuthor 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 .

 

Contact: mstack@reduceyourworkerscomp.com.

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

 

©2018 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.

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