11th Annual Meeting & Educational Conference

Table of Contents

Welcome .................................................................................................................................. 2Agenda ...................................................................................................................................... 4

2015 Partners .......................................................................................................................... 10

Speaker Biographies .............................................................................................................. 12

Educational Sessions ................................................................................................................ 21

Top 10 Submitter Errors .............................................................................. 21

Ethics in the MSP Industry ............................................................................ 34MSP Compliance Situational Case Study ................................................ 44Perspectives on MSP Compliance .............................................................. 56

Applying the Science of Evidence Based Medicine (EBM) Guidelines to Fusions for Injured Workers ................................................................... 62Affordable Care Act and Its Effect on MSAs ......................................... 89Long-Term Narcotic Use in MSAs .............................................................. 114Legal Update ................................................................................................ 146Re-Review / Reconsideration ..................................................................... 153Data & Development Committee Update ............................................... 164Limited Medical Records and the MSA: What Do You Do? ................ 170Private Cause of Action .............................................................................. 179State Workers’ Compensation Laws and CMS: Do They Matter? ...... 188Weaning and Detox Strategies in the MSA ........................................... 211Case Study: Liability MSAs – Where are we now? Do They Have a Place in your Settlement? ........................................................................... 240Pharmacy Formularies and the MSAs ...................................................... 241Snappy Answers to Common Questions ................................................... 265

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Dear Meeting Attendees:

Thank you so much for taking time out of your busy schedules to join us here in New Orleans for NAMSAP’s 11th Annual Meeting and Conference! We are delighted to have you here and are dedicated to making your time with us both worthwhile and enjoyable.

We have some great speakers lined up to share their industry insights with you. We also encourage you to take advantage of your time here to meet and network with fellow NAMSAP members and conference attendees. This is truly a great opportunity to establish connections with those you have only “seen” on the NAMSAP listserv, so please don’t hesitate to introduce yourself in person.

NAMSAP is honored to have some very generous sponsors for this event, without whom it would not be happening, please join me in thanking the sponsors for their support!

KP Underwriting, LLCEPS Settlements Group

FIG Nursing Education and ConsultancyFranco Signor, LLC

Louisiana Association of Self-Insured Employers (LASIE)Rising Medical Solutions

ODG/Work Loss Data Institute (WLDI)

Last, but certainly not least, we’re fortunate to be here in The Big Easy, right on Bourbon Street. We encourage you to join us for our Thursday evening reception before heading out to see and experience this wonderful area.

On behalf of myself, our board members and our Annual Meeting Sub-Committee, we thank you so much for attending and we greatly appreciate your continued support!

Warm regards,

Kimberly A. WiswellPresident – 2015

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Hello Fellow Meeting Attendee:

Welcome to New Orleans for the 11th NAMSAP Annual Meeting and Educational Conference! On behalf of the Board of Directors and the Annual Meeting Sub-Committee, I want to thank you for attending the conference and hope you enjoy yourself over the next few of days.

NAMSAP has once again assembled a top notch agenda that will be sure to deliver the latest news surrounding the MSP compliance industry. The Annual Meeting Sub-Committee, including Christine Melancon, Gary Patureau, Leslie Schumacher and Monica Williams have worked tirelessly to bring together some of the best and brightest minds in our industry. Our speakers have devoted a tremendous amount of time to help create a top tier program from which all of us will benefit.

Once again, thank you so much for attending the conference. I hope you enjoy your time here in The Big Easy, and I look forward to meeting you over the next few days.

Kindest Regards,

Tom MatsonChairmanAnnual Meeting Sub-Committee

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11th Annual NAMSAP Meeting & Educational ConferenceSeptember 30 - October 2, 2015Royal Sonesta Hotel New Orleans

Wednesday, September 30, 2015

Pre-Conference Sessions Agenda7:30 - 8:00 am

Continental Breakfast Foyer8:00 am - 9:00 am Grand Ballroom

Top 10 Submitter ErrorsSubmitting an MSA to CMS can be a daunting task. This session will shed some light on this tedious undertaking and spell out some of the common mistakes made during the process.

PanelistsCarmen Bullard - Concierge Medical & Risk Consultants

9:00 am - 10:00 am Grand BallroomEthics in the MSP IndustryWith no clear-cut laws guiding the settlement community on exactly how to protect Medicare’s interest as a secondary payer, the line is often blurred between right and wrong. Our panelists will discuss several real-world scenarios that will create a stimulating conversation and raise opposing viewpoints on different methods of proper MSP compliance.

PanelistsDenis Paul Juge - Juge, Napolitano, Guilbeau, Ruli & FriemanKayla Tortorich - WellComp Managed Care ServicesMonica Williams - MWC Associates, LLC

10:00 am - 10:30 am Break with Exhibitors

Foyer

10:30 am - 11:30 am Grand BallroomMSP Compliance Situational Case StudyProper MSP compliance can be a tricky undertaking. Without a proper foundation, there are many pitfalls that can lead the practitioner astray. This case study will review a scenario from start to finish while addressing many aspects of MSP compliance along the way.

PanelistsFran Provenzano - Medicare Set-Aside Specialists, Inc. Thomas Spratt - ProtocolsThomas Stanley - Stanley Insurance Agency, Inc.

11:30 am Pre-Conference Sessions Adjourn

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Conference Sessions Agenda

1:00 pm - 1:05 pmConference Welcome Tom Matson - Chair, Annual Meeting Sub-Committee

Grand Ballroom

1:05 pm - 1:15 pmPresident’s Message Kimberly A.Wiswell - President

Grand Ballroom

1:15 pm - 2:30 pm Grand BallroomPerspectives on MSP Compliance The MSP compliance industry has soared over the past decade. The pace is fast and it is often easy for a practitioner to lose sight of how their body of work affects the end user. You will not want to miss this opportunity to hear our panelists discuss their views on the MSP compliance industry from the carrier perspective.

PanelistsSteve M. Pratt - Berkley Southeast Insurance Kathleen Wyeth - Accident Fund Holdings, Inc.

2:30 pm - 3:00 pmBreak with Exhibitors

Foyer

3:00 pm - 4:00 pm Grand BallroomApplying the Science of Evidence Based Medicine (EBM) Guidelines to Fusions for Injured WorkersNAMSAP continues to promote and endorse EBM guidelines as a more effective and efficient means of projecting future medical needs. Our speaker will address the science behind EBM guidelines, and more specifically, how to apply these guidelines to spinal fusions.

PanelistsMarjorie Eskay-Auerbach - SpineCare and Forensic Medicine, PLLC

4:00 pm - 5:00 pm Grand BallroomAffordable Care Act and Its Effect on MSAsPresident Barack Obama signed the Affordable Care Act (ACA) into law in 2010. This controversial new law provides access to healthcare for millions of Americans that otherwise could not have obtained coverage. Our panelists will explain the intricacies of this new law as well as the effects the ACA has on the cost of a claim-ant’s future medical needs.

PanelistsPatrick Hindert - S2KM Limited Ann Koerner - National Care Advisors

5:30 pm - 6:30 pm Evangeline SuitePrivate ReceptionDinner on your own

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Conference Sessions Agenda Thursday, October 1, 2015

7:45 am - 8:45 amBreakfast with Exhibitors

Foyer

9:00 am - 10:00 am Grand BallroomLong-Term Narcotic Use in MSAs Prescription drugs are known to escalate the cost of an MSA exponentially. While the short term use of narcotics to treat certain conditions has proven to result in beneficial outcomes, long-term use of these medications can have lethal results. Our panelists will discuss the long term effects of narcotics on the body, and present evidence indicating why their long-term use in an MSA should be minimized.

PanelistsSteven J. Miller - SJM EnterprisesMeredith Warner - Warner Orthopedics and Wellness

10:00 am - 10:30 amBreak with Exhibitors

Foyer

10:30 am - 11:30 am Grand BallroomLegal Update In what has become a NAMSAP tradition, you are not going to want to miss the annual Legal Update. Court cases across the country continue to address MSP compliance issues. Our panelists will introduce new cases that have transpired over the year, and offer up their own legal commentary on the ramifications of these decisions.

PanelistsAnnie Davidson - O’Meara, Leer, Wagner & Kohl, PAMichele E. Ready - Walton Lantaff Schroeder & Carson, LLP Heather Schwartz Sanderson - Franco Signor, LLC

11:30 am - 1:00 pmNetworking Lunch

Fleur de Lis & Courtyard

1:00 pm - 3:00 pm ALLOCATOR TRACK

1:00 pm - 2:00 pm Grand BallroomRe-Review / Reconsideration The preparation of an MSA can be a complicated task. Allocators make their best effort to ensure they are providing the most accurate projection of future medical costs they can, but what does one do when an error is made or records were omitted that can affect the final number that was approved by CMS? Our expert panelists will discuss circumstances surrounding this issue, and a best practices approach to reaching a resolution.

PanelistsMichelle Letter - NovareJeff Knipper - Contact Claims Services, Inc.James R. Raines - Breazeale, Sachse & Wilson, LLP

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2:00 pm - 2:30 pm Grand BallroomData & Development Committee Update NAMSAP’s Data & Development Committee (DDC) was created several years ago with the goal of compiling data and identifying trends surrounding the projection of future medical costs within an MSA, and the subsequent approval and/or counter from CMS. Our panelists from DDC will present the most updated information they have compiled over the last 18 months to help identify trends that will help lead to a more efficient and cost effective MSA.

PanelistsDebbe Marcinko - Marcinko Consulting, LLCSandra Mackler - Mackler Associates, LLC

2:30 pm - 3:00 pm Grand BallroomLimited Medical Records and the MSA: What Do You Do? There are many instances where a petitioner has not obtained much treatment over the course of the last two years. If that injured individual meets certain criteria, an MSA could still be appropriate for them, but the lack of medical treatment could make it difficult to accurately project future medical expenditures. Our expert will discuss some instances that could lead to a small amount of records, and more importantly, steps that can be taken to prepare an accurate MSA in lieu of this problem.

PanelistsDenise W. Wrenn - Cleco Corporation

1:00 pm - 3:00 pm LEGAL TRACK1:00 pm - 2:00 pm Evangeline Suite A/B

Private Cause of Action The MSP Private Cause of Action (PCOA) has created a firestorm of controversy over the past year. Our pan-elists will discuss situations that could lead to a PCOA, and its effect on the MSP compliance process.

PanelistsAmy E. Bilton - Nyhan, Bambrick, Kinzie & Lowry, PCHeather L. Hatch - The Chartwell Law Offices, LLP

2:00 pm - 3:00 pm Evangeline Suite A/BState Workers’ Compensation Laws and CMS: Do They Matter? There is an underlying conflict over recommendations and preferences issued by CMS, and state workers’ compensation laws. The dispute can sometimes boil over with direct conflicts that can jeopardize settlements. Our panel of experts will discuss the complexities of this conflict and offer manageable solutions to the problem.

PanelistsJennifer C. Jordan - MEDVAL, LLCDanielle E. Marone - Schmidt, Dailey & O’Neill, LLC

3:00 pm - 4:30 pmBreak with Exhibitors

Foyer

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4:30 pm - 5:30 pm Grand BallroomWeaning and Detox Strategies in the MSA The cost of prescription medications in an MSA can escalate the projection exponentially. Proper atten-tion must be given to drug use, and appropriate steps must be taken to successfully eliminate these costly medications from the MSA. Our panelists will discuss tried and true methods that will help wean the injured individual off of these dangerous medications which ultimately will facilitate a mutually beneficial settlement.

PanelistsJill Breard - LWCCJennifer Doherty - Paradigm Outcomes Steven M. Moskowitz - Paradigm Outcomes

5:30 pm - 6:30 pmReception

Evangeline Suite/Foyer

Conference Sessions Agenda Friday, October 2, 2015

7:15 am - 8:00 amBreakfast with Exhibitors

8:00 am - 9:00 am ETHICS Grand BallroomCase Study: Liability MSAs – Where are we now? Do They Have a Place in your Settlement? The controversial topic of MSAs on liability cases continues to be debated throughout the industry. Some feel LMSAs are appropriate in some cases, others cringe at the slightest mention of the phrase. Our panelists will present a case study that addresses the role an MSA could play within the context of a liability settlement.

PanelistsDavid R. Cherry - Cherry Injury Law Wayne Fontana - Roedel Parsons Koch Blache Balhoff & McCollister ModeratorGreg Gitter - Gitter & Associates, Inc.

9:00 am - 9:30 amBreak with Exhibitors

Foyer

9:30 am - 10:30 am Grand BallroomPharmacy Formularies and the MSAsPharmacy formularies have proven to be effective when created and utilized appropriately. The lack of a specific formulary in the MSA has shown to result in out of control future medical costs that are unrealistic and unobtainable. Our experts will discuss the benefits of using a pharmacy formulary for MSA purposes, and present evidence supporting that its implementation can achieve effective care for the petitioner while at the same time limiting costs for the settling parties.

PanelistsSteven D. Feinberg - Feinberg Medical GroupMatthew P. Foster - HELIOSMark Pew - PRIUM

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10:30 am - 11:30 am Grand Ballroom

Snappy Answers to Common QuestionsWe’ve all been asked MSP-related questions which cause us to pause and make sure our mouths are not verbalizing the answer we just said to ourselves in our heads. You are not going to want to miss this presentation that will capture these situations in a humorous light as we wind down the Annual Meeting and prepare for our travels home.

PanelistsChristine Melancon - Ez-MSA

11:30 am - 12:00 pmConference Wrap Up

Grand Ballroom

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Thank You to our Sponsors!

Continuing EducationNAMSAP has been approved for 14.25 credit hours in:

CWCP, CMSP, CRC, CCM, MSCC, CLCP/CCLCP, CNLCP, Lousiana CLE and Florida CLE.

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Thank You to Our Partners for their SupportGold Partner

Bronze Partners

Silver Partners

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Amy E. Bilton, JD, MSCCAmy E. Bilton, Esq. is a shareholder and workers’ compensation defense trial attorney at the Chicago law firm of Nyhan, Bambrick, Kinzie, and Lowry. She received her BA from the University of Michigan, JD from DePaul University College of Law and has her MSCC certification. Ms. Bilton is a frequent lecturer on workers’ compensation, Medicare Secondary Payer issues and Medicare Set-Asides. In addition to being a NAMSAP member and legal committee chair, she is a member of the Chicago Bar Association, Illinois State Bar Association and Illinois Workers’ Compensation Lawyers Association. She has specific interest in bringing evidence-based medicine to MSAs.

Jill Breard, CWCP Jill Breard was promoted to Assistant Vice President of Claims Operations in 2013. She joined LWCC originally in March 1993 as a claims representative, advancing to senior claims representative and then later to rehabilitation services coordinator. She transitioned to her current role via Operations Manager and then Director of Operations for the Claims Department. In 2013, she was named Assistant Vice Present of Claims Operations leading the Occupational Medicine and Claims Operations units. Occupational Medicine includes LWCC’s Occupational Medicine Network (OMNET), Medical Services, as well as oversight of Utilization Review and the Pharmacy Benefits Management program. The Claims Operations unit includes Claims Intake, SIU, Training and Compliance, Medical Bill Review and management of the multi-state claims program. Previous experience includes work as a vocational rehabilitation counselor, Director of Claims and Litigation for the Louisiana Restaurant Association, and most recently in state government as the Director of the Louisiana Second Injury Board. Ms. Breard earned a BS in Mathematics and Psychology from Louisiana State University in Baton Rouge and as well as a Master of Education (MEd) in Community Counseling from Southeastern Louisiana University. She maintains her status as a Licensed Vocational Rehabilitation Counselor. In addition, Ms. Breard serves as an instructor for the Louisiana Association of Self Insured Employers (LASIE) CWCP program. Ms. Breard has also served on several OWC task force groups in the areas of EDI (electronic data interchange), electronic medical billing, fraud, and fee schedule updates.

Carmen Bullard, BS, MSCCMs. Bullard has held the role of Director, Medicare Secondary Payer for Concierge & Risk Consultants since 2008. There she provides a variety of consulting services in regard to Medicare Secondary Payer, Medical Cost Analysis, and Complex Catastrophic Claims. She received her BS at Gardner-Webb University and is Medicare Set Aside Consultant Certified and is a Licensed Adjuster in North Carolina. She is a member of the National Alliance of Medicare Set Aside Professionals (NAMSAP) and Alamance Claims Association (ACA).

Ms. Bullard also has an accomplished list of Research, Publications, and Presentations. They are as follows: April 2, 2014 Mastering the Medical Portion of the Claim, March 14 – 17, 2013 Leisure and Learn Conference. Medicare Set Asides, February 7, 2013 Medicare Secondary Payer 2013 Update. Information on The SMART Act, Conditional Lien Negotiation, MSAs and Medical Cost Projections, October 25, 2012 Medicare: Impacting Your Settlements, and October 20, 2011 Protecting Medicare Process, Problems and Pitfalls Seminar: Satisfying Conditional Liens, Future Medical Treatment, Common Pitfalls, Obtaining an Accurate Medical Projection, Additional Medicare Settlement Considerations.

David R. Cherry, Esq., CMSPDavid R. Cherry has been the driving force behind a law practice built with an emphasis on workman’s’ compensation & serious personal injury. His practice encompasses all types of personal injury including work injuries. He is a graduate of Widener School of Law (JD) and Temple School of Law (Masters in Trial Advocacy). Mr. Cherry has been recognized for several distinctions throughout both his academic and professional career.

11th Annual Meeting & Educational Conference

Speaker Biographies

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Annie M. Davidson, Esq., CMSPAnnie M. Davidson concentrates her practice in the areas of Medicare Secondary Payer Act compliance, and liability and workers’ compensation insurance defense. She is a Certified Medicare Secondary Payer Professional (CMSP) and presents at conferences locally on issues related to Medicare compliance.

Ms. Davidson is admitted to practice in the State Courts of Minnesota. She is a member of the American Bar Association, the Minnesota State Bar Association, and the Hennepin County Bar Association. She is also a member of the Minnesota Defense Lawyers Association, Minnesota Women Lawyers and the National Alliance of Medicare Set-Aside Professionals.

Ms. Davidson graduated cum laude from William Mitchell College of Law. While attending law school, she received awards for achieving the highest grade in Contracts, Professional Responsibility, and European Union Law. Ms. Davidson received her Bachelor of Arts degree from the University of Minnesota, Twin Cities where she was the recipient of the President’s Student Leadership and Service Award and the University-YMCA Kimberly Ann Paulsen Award for Outstanding Service.

In her free time, Ms. Davidson plays rec sports. She is also board secretary for the District 5 Payne Phalen Community Council in Saint Paul where she is active in local community affairs.

Jennifer DohertyAs Director of Clinical Services, Jennifer Doherty coordinates implementation of Paradigm’s Systematic Care Management SM model and oversees case, clinical and financial management to achieve optimal outcomes. Jennifer has worked in healthcare for more than 20 years, focusing on clinical and administrative management of patients with chronic pain, traumatic brain injury, spinal cord injury and respiratory conditions.

Before coming to Paradigm, Jennifer worked as a Clinical Supervisor and now business owner for Palmetto Rehabilitation Services, LLC. She has 20 years of clinical experience including work as an Occupational Therapist specializing in brain injury rehab, as well as experience in various other diagnoses in acute rehab and acute care setting. Jennifer was the Director of the Driving Program at Fairlawn Rehabilitation Hospital in Worcester, Massachusetts and she developed a hand therapy clinic while working in the outpatient setting. She also worked at Windham Group, a New England based company, where she assisted in pharmaceutical reviews, field case management, Medicare Set Asides and medical cost projections.

Jennifer is certified as a Life Care Planner, working with both plaintiff and defense counsel, as well as a Medicare Set Aside Consultant where she is now actively involved in the NAMSAP organization. She holds a degree in English and a minor in business from the University of South Carolina. In addition, Jennifer has a degree in Occupational Therapy from Worcester State College where she graduated with honors.

Marjorie Eskay-Auerbach, MD, JDMarjorie Eskay-Auerbach, MD, JD, is a board-certified orthopedic surgeon with fellowship training in spine surgery and an attorney. She is a medical-legal consultant with a special interest in spine care and evidence-based management of orthopedic conditions, author and frequent lecturer nationally. Dr. Eskay-Auerbach earned both her undergraduate and medical degrees at the University of Michigan, where she was a student in the combined six-year program. She did her Orthopedic Surgery residency at the University of Pittsburgh Health Sciences Center and her spine fellowship with Leon WIltse, M.D., in Long Beach, CA. She received her JD from the University of Arizona, in 2001, and is a member of the Arizona bar and the Forensic Expert Witness Association. She is an active member of the North American Spine Society, and served as a member of the Board of Directors. She is an active educator for the AMA and was a contributing editor of the musculoskeletal chapters in the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition. She co-authored Transition to the AMA Guides Sixth and a number of workbooks related to use of the Guides. She has contributed chapters to a number of AMA publications including Guides the Evaluation of Disease and Injury Causation, 2nd Edition and AMA Guides to the Evaluation Work Ability and Return to Work. She is a contributor to Official Disability Guidelines and has participated in efforts to adopt ODG in Arizona.

Dr. Eskay-Auerbach has over 30 years of clinical experience in worker’s compensation. She previously practiced spine surgery and non-operative care of spinal conditions. Her current clinical practice in Tucson, AZ is in occupational orthopedics and she performs medical-legal consultations, independent medical evaluations, record reviews and reviews of impairment ratings, as well as expert opinions and testimony. She holds medical licenses in AZ, CA, NM and OK.

Steven D. Feinberg, MD, MPHDr. Steven Feinberg is a physiatrist and pain medicine specialist practicing in Palo Alto. He is an Adjunct Clinical Professor and teaches at the Stanford University Pain Service.

Dr. Feinberg is a past president (1996) of the American Academy of Pain Medicine (AAPM). He served as a California Society of Medicine & Surgery (CSIMS) Year 2001 President. He serves on the Board of Directors of the American Chronic Pain Association (www.theacpa.org) and is lead author of the 2015 ACPA Consumer Guide to Pain Medication & Treatment. He is the Medical Advisor to Cedaron AMA Guides Software.

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Dr. Feinberg received the 1998 Professional of the Year Award from the California Governor’s Committee on Employment of the Disabled. He is the recipient of the 1999 American Academy of Pain Medicine Founders Award. In 2006, he received both the Silver Scalpel Award by CSIMS and the Stanford Pain Management Center Award for Teaching Excellence.

Dr. Feinberg served on the ACOEM Chronic Pain Guidelines Panel Chapter Update and also as Associate Editor, as a Medical Reviewer for the ACOEM 2014 Opioid Guidelines and he also serves ongoing as a Medical Consultant to the Official Disability Guidelines (ODG) and on the Reed Group’s Medical Advisory Board. He served as a Reviewer for the AMA Guides to the Evaluation of Permanent Impairment, 6th Edition. He is on the AMA Guides Newsletter Advisory Board ongoing.

Wayne Fontana, Esq., CWCPWayne Fontana has served as legal consultant to Louisiana Governors Treen, Roemer, Foster and Jindal. He currently serves as the Managing Shareholder in the New Orleans office of the ROEDEL, PARSONS, KOCH, BLACHE, BALHOFF & McCOLLISTER law firm. For three decades, he has drafted numerous legislative bills, testified before the Louisiana legislature on behalf of business interests and the aforementioned governors, and lobbied and helped pass all major tort reform and workers’ compensation reforms since 1983. Through gubernatorial appointments, he has served on the Advisory Council for the Office of Workers’ Compensation for multiple terms. He is general counsel for LASIE (Louisiana Association of Self Insured Employers) and teaches its nationally recognized CWCP (Certified Workers’ Compensation Professional) Program. He is a founder and member of the board of directors of Citizens Against Lawsuit Abuse. Mr. Fontana has served the New Orleans Regional Chamber of Commerce as its vice chairman, as chairman of its legislative committee and public policy committee and as a member of its board of directors, executive cabinet and Council of Governments. For over 30 years, he has been committed to and very involved with the state chamber, the Louisiana Association of Business and Industry (LABI), serving on its board of directors and executive committee and chairing numerous committees, councils and task forces devoted to workers’ compensation and tort reform. On liability and workers’ compensation matters, Mr. Fontana serves as one of the chief spokespersons for the business community, appearing frequently on television, radio and the internet, in the print media and as a seminar speaker. Mr. Fontana practices primarily in the areas of workers’ compensation defense, personal injury defense, casualty and insurance defense and governmental affairs.

Matthew P. Foster, PharmDAs the Clinical Pharmacy Manager, Dr. Matthew Foster oversees the Clinical Services production team that is responsible for all of the prescriber intervention services that help ensure that the right medications are being utilized at the right time. He also works closely with the clinical liaisons and design teams to provide enhanced and new clinical services for Helios clients.

Matt has significant experience evaluating complex pharmacotherapeutic pain management issues confronting the workers’ compensation industry. He is experienced in performing therapeutic reviews and interventions for workers’ compensation claims. He has also developed and implemented numerous clinical programs to improve the medication therapy of injured workers.

He has conducted educational activities for hundreds of nurses, adjusters, pharmacists, and other health care practitioners within the workers’ compensation industry, as well as other healthcare venues. Matt also serves on the Editorial Advisory Board for the Work Loss Data Institute, which publishes the Official Disability Guidelines (ODG). In this role, he provides recommendations and input into the contents of the ODG formulary. He holds an appointment as a Clinical Assistant Professor with the University of Florida College of Pharmacy and Lee County College of Medicine, and teaches drug information and managed care clinical rotations to senior Doctor of Pharmacy students.

Prior to his position at Helios, Matt was a pharmacy director and clinician specializing in internal medicine, critical care, and acute pain management at a large community hospital.

Dr. Foster holds a Doctor of Pharmacy degree from the University of Florida College of Pharmacy and is licensed as a pharmacist in Florida. He is also a member of several professional organizations.

Greg Gitter, CMSPGreg Gitter is the President of Gitter & Associates, Inc., a firm specializing in negotiating resolution of High-Exposure Work-ers’ Compensation claims for excess carriers, employers, insurance companies and any other parties involved in Workers’ Compensation claims. Greg has been involved in the Workers’ Compensation arena for 18 years in various capacities and in numerous jurisdictions, both at the State and Federal levels. He has gained extensive knowledge and experience related to the interaction between Medicare and the Medicare Secondary Payer (MSP) Statute relative to Workers’ Compensation. Over the years, Greg directed his focus on the impact of Long Term, High Exposure, Complex and Catastrophic Workers’ Compensation claims and he developed a specialized skill set and specific strategies to identify and resolve these claims to the mutual benefit of all parties involved. Greg was recognized by LexisNexis as one of the Workers’ Compensation Notable People for 2008 and was a member of the inaugural CMSP class of 2010. Most recently, he was published in the Complete Guide to Medicare Secondary Payer Compliance (2012) and has been an active member of the NAMSAP Educational and Membership committees for the past several years.

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Heather L. Hatch, Esq.Heather L. Hatch is a partner in the Jupiter office of The Chartwell Law Offices, LLP. Prior to that she was a partner with a Southeast firm. Ms. Hatch is a trial attorney practicing in the areas of civil litigation. A focal part of her practice involves the representation of employers, self-insured employers, and their insurance carriers in all aspects of workers’ compensation claims and employment related matters in Florida. She represents a variety of employers throughout the state of Florida before administrative judges, circuit courts and Judges of Compensation Claims. Ms. Hatch’s practice areas also include Medicare Compliance, 111 reporting issues, and MMSEA compliance in both workers’ compensation and liability claims. In addition to litigation, Ms. Hatch offers workplace education which aim at enhancing risk prevention, effective incident reporting and decreasing potential litigation that may stem from workplace or disability issues. Ms. Hatch is also a frequent lecturer throughout the state of Florida and other jurisdictions on workers’ compensation, Medicare Compliance and Employment related issues. Ms. Hatch is certified as an educator with the State of Florida.

Ms. Hatch received her Juris Doctor, cum laude, from the University of Florida in 2000 and a Bachelor of Arts, from Wittenberg University, Springfield, Ohio in 1997.

Ms. Hatch is licensed to practice law in Florida and Tennessee. She is a member of The Florida Bar and Tennessee Bar. She is also admitted in the U.S. District Courts of the Northern, Middle, and Southern Districts of Florida; and U.S. Court of Appeals for the Eleventh Circuit. Her professional affiliations include The Florida Bar (Workers’ Compensation Section and Labor and Employment Sections), the American Bar Association (Workers’ Compensation and Labor and Employment Sections), The Palm Beach County Bar Association (including serving on the Professionalism Committee and the Workers’ Compensation Committee), Florida Association of Women Lawyers and associate member of the Palm Beach Chapter of RIMS. Ms. Hatch is also active in several community organizations and local scholarship funds.

Patrick Hindert, JDPatrick Hindert is an attorney, author, educator and online journalist who resides in Warren County, Ohio and specializes in structured settlements and personal injury settlement planning. Hindert is a member of the Ohio Bar Association. He is a graduate of Harvard University and the University of Michigan Law School.

Prior to entering the structured settlement industry in 1977, Hindert taught French and coached varsity tennis at Cranbrook Academy in Bloomfield Hills, Michigan and practiced trust and estate law in Michigan and Ohio. In 1995, Hindert served as Chairman of the Board of Directors of R.A. Jones, Inc., an international packaging machinery company headquartered in Northern Kentucky. Hindert previously served as Managing Director of the Settlement Services Group from 2009 to 2013 and currently is Managing Director for S2KM Limited.

Hindert has been a leader within the United States structured settlement industry since its inception. He co-founded Benefit Designs, Inc. in 1977 and developed it into a national structured settlement intermediary before selling the company in 1998. Hindert has previously served as President of the National Structured Settlement Trade Association (NSSTA) and Executive Director of the Society of Settlement Planners (SSP). The National Association of Settlement Purchasers (NASP) honored Hindert as the 2012 recipient of its Alexander Hamilton award.

Hindert co-authors “Structured Settlements and Periodic Payment Judgments”, a legal treatise published in 1986 by Law Journal Press and updated semi-annually. Both NSSTA and SSP feature “Structured Settlements and Periodic Payment Judg-ments” in their certification programs. Hindert also authors S2KM’s blog “Beyond Structured Settlements” and S2KM’s public wikis including the “structured settlement wiki” and the “web 2.0 for lawyers wiki.”

Jennifer C. Jordan, JD, MSCCJennifer Jordan is General Counsel and a founding member of MEDVAL, LLC. Starting with the first CMS memo on MSAs and workers’ compensation, Jen has focused on providing practical advice and in-depth knowledge to virtually every type of en-tity subject to Medicare Secondary Payer (MSP) compliance. From MSAs to MMSEA reporting, she counsels clients while moni-toring the legal landscape to identify and analyze emerging legal issues and trends affecting MSP impact and compliance.

Jen is recognized as a leading authority on Medicare Secondary Payer compliance and has devoted much time to educating attorneys and other professionals. She is Editor-in-Chief of The Complete Guide to Medicare Secondary Payer Compliance, published by LexisNexis. She recently received the 2010 Workers’ Compensation Notable People Award from the Lexis-Nexis Workers’ Compensation Law Community. Her article, “Medicare Secondary Payer Enforcement: Shifting the Burden of Medicare to the Private Sector” was published in The Brief, the magazine of the Tort and Insurance Practice Section of the American Bar Association. She is often quoted in industry publications. In addition to writing and speaking, she is designated as an expert witness by the United States Department of Justice for her extensive knowledge of MSP issues.

Jen received her JD from the University of Baltimore, School of Law where she was a member of the Law Review and acting Editor-in-Chief of the University of Baltimore Intellectual Property Law Journal. She received her MBA from the University of Baltimore, Robert G. Merrick School of Business. She received her BA in Economics and Fine Arts from Virginia Polytechnic Institute and State University.

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Denis Paul Juge, JDDenis is a director in the law firm of Juge, Napolitano, Guilbeau, Ruli, & Frieman, in Metairie, Louisiana. He obtained his Bachelor of Arts degree from the University of New Orleans in 1970 and his Master of Arts from the University of New Orleans in 1972. He received his juris doctor degree from Loyola University School of Law in 1976. Denis’ practice area is state and federal workers’ compensation and employer’s liability (Louisiana and Mississippi). Since 1983 he has worked with the Louisiana Association of Business and Industry (LABI) to support pro-business legislation. He has taught Insurance Law and Workers’ Compensation Law at Loyola Law School from 1982 to 2005 and is the author of two books on Louisiana workers’ compensation as well as numerous Law Review articles.

Jeff Knipper, MSCC, CMSPJeff Knipper is the Director of Medicare Services for Contact Claims Services Incorporated. Mr. Knipper has spent 20 years in the workers’ compensation claims business focusing on Longshore/NAF claims. He has experience working with all of the regional offices of the U. S. Department of Labor, Longshore Division to resolve claims. He has provided expert testimony before Administrative Law Judges at formal hearings. His current responsibilities include Medicare Set-Aside development, CMS submissions, and MMSEA Section 111 reporting compliance. He received a Bachelor of Science in Finance from the University of South Alabama. Mr. Knipper also completed the MSA Pre-Certification Program at the University of Florida and currently holds the Medicare Set Aside Consultant Certified credential.

Ann Koerner, RN, BSN, CRRNAnn Koerner is President of National Care Advisors – a firm dedicated to providing consulting services for attorneys, financial planners and trustees. National Care Advisors provides care and quality of life planning services for those families faced with physical disability, mental illness, developmental disability, or eldercare issues. Services include planning and case management applicable to Special Needs Trusts and government benefits preservation. National Care Advisors also specializes in post-litigation resolution consulting services specific to lien negotiation, Medicare Set Aside projections and administration. Prior to the inception of National Care Advisors in 2008, Ann’s nursing practice has been dedicated to developing effective disability management solutions for injured and ill workers.

As a result of her work with many national corporations, Ann possesses extensive business knowledge of case management, utilization review, third party payers, workers’ compensation, private insurance companies and government resources. Ann received her Bachelor of Science in Nursing degree in 1981 from Russell Sage College in Troy, New York. She began her nursing practice as a Public Health Nurse in New York and then continued that practice with the City of Columbus Health Department.

In 1992, Ann became a case manager with the national case management company, Concentra, focusing on the management of complex catastrophic workers’ compensation and disability claims throughout the United States. Her duties were expanded to include marketing and management of case management services in Ohio for this company. In 1996, Ann was selected to become the Director of Medical Operations and Self-Insured Marketing for CareWorks, the largest workers’ compensation managed care organization in Ohio.

Michelle Letter, RN, CCM, MSCC, LNCC, CMSPMichelle began her nursing career working in the hospital and clinical setting. Thereafter, she spent four years in the insurance industry, specializing in utilization review, case management, coding, and reimbursement. Seven years ago, she transitioned from the insurance industry into Medicare Secondary Payer compliance, and became certified as a Medicare Set Aside Consultant, Medicare Secondary Payer Professional, Legal Nurse Consultant, and Case Manager. Since that time, she has acquired multiple areas of expertise in the field of Medicare Secondary Payer (MSP) compliance. These areas include Mandatory Insurer Reporting, conditional payment and final lien research and resolution, and Medicare Set Aside allocation and submission. In addition to her MSP duties, she also performs Medical Cost Projections, Social Security Benefit Verifications, and Medical-Legal consulting.

Michelle is a member of NAMSAP (National Alliance of Medicare Set Aside Professionals) and AALNC (American Association of Legal Nurse Consultants); has provided both adjuster and legal continuing education; and is a previous speaker at the NAMSAP conference. She is an active member of the Data and Development Committee of NAMSAP. Currently, Michelle works as a consultant for Novare.

Sandra Mackler, MEd, CRC, CDMS, MSCCMs. Mackler has over 28 years’ experience providing a wide range of services to insurers, self-insured employers and attorneys. She has focused primarily on Medicare Set-Asides for the past 12 years. Ms. Mackler is recognized as an expert witness, and has testified in both workers’ compensation and personal injury cases. She has been a Guest Lecturer at the University of Massachusetts School of Managements on Workers’ Compensation matters, and has been a Guest Speaker at the Connecticut Trial Lawyers Association on Medicare Set-Asides.

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Debbe Marcinko, RN, BSN, MA, CRN, CMC, CRC, CLCP, CNLP, MSCCA registered nurse for more than 39 years, Debbe has been developing Workers Compensation Medicare Set-asides since 2005. Debbe holds a Bachelor of Science degree in nursing, a Master’s Degree in rehabilitation counseling, and certifications in rehabilitation nursing, case management, rehabilitation counseling, life care planning and Medicare set-asides. She has been in private practice since 2000, relocating to Pittsburgh in 2012.Debbe is an active member of the National Alliance of Medicare Set-aside Professionals (NAMSAP), American Nurses Association, Association of Rehabilitation Nurses, International Association of Rehabilitation Professionals, International Academy of Life Care Planners (IALCP), American Association of Nurse Life Care Planners and Sigma Theta Tau. She is currently the Chair of the Life Care Planning section of IARP, and a member of the Data & Development Committee of NAMSAP.

Danielle E. Marone, Esq.Danielle E. Marone, Esquire is an associate attorney at Schmidt, Dailey & O’Neill, L.L.C. Her practice areas include defending clients in commercial liability, employment discrimination, and workers’ compensation claims, with a focus on Medicare set-asides. She was formerly a Health Insurance Specialist with the Centers for Medicare and Medicaid Services (CMS) and the Government Task Leader for the Workers’ Compensation Medicare Set-aside Arrangement (WCMSA) project. She was instrumental in drafting CMS’ policy memorandum regarding the inclusion of prescription drug expenses in WCMSAs. She was also responsible for monitoring and assisting CMS’ Workers’ Compensation Review Contractor in implementing CMS’ WCMSA operating rules. She functioned as a policy expert regarding the WCMSA initiative for CMS’ 10 Regional Offices, Medicare beneficiaries, claimants, insurers, and attorneys. Danielle obtained her BA at Villanova University and her JD at Case Western University School of Law. She was admitted to the Maryland Bar in 1999 and the District of Columbia Bar in 2006. She is a member of the Maryland and District of Columbia Bars, and the Maryland Defense Counsel.

Christine Melancon, RN, CCM, MSCC, CMSP, CNLCPChristine M. Melancon is the Vice President of operations for Ez-MSA, a company specializing in Medicare Set-Asides as well as other products which assist clients with Medicare Secondary Payer (MSP) compliance. Christine is a proud graduate of Charity Hospital School of Nursing in New Orleans, La., and is a registered nurse who holds certifications as a case manager (CCM), as well as a Medicare Set Aside Consultant Certified (MSCC), and was among the first in group of those who obtained the Certified Medicare Secondary Payer Professional (CMSP) designation. In addition, Christine has earned her designation as a Certified Nurse Life Care Planner (CNLCP). Christine is a member of NAMSAP (Annual Meeting Sub-Committee), the American Association of Nurse Life Care Planners, and the Louisiana Association of Self Insured Employers (LASIE). Christine is an MSCC certified instructor through the International Commission for Health Care Certification and has served as a mentor to a multitude of individuals new to MSP compliance issues, including allocators, brokers, adjusters, and attorneys.

Steven J. Miller, MSPharm, DPh, RPhSteven J. Miller, MSPharm, DPh, RPh, is president of SJM Enterprises, a multi-faceted consumer-response organization, specializing in workers compensation issues, Medication Set Aside programs, formulary review and analysis, provider intervention, medication therapy management, and managed care pharmaceutical reimbursement issues. He is a clinical pharmacist with many years of experience in managed care workers compensation, Medicare, and Medicaid pharmacy consulting. He is also a part time dispensing pharmacist with Walgreens.

He has served in several capacities with many types of managed care organizations, and has made numerous regional and national presentations on issues such as medication issues for the elderly, cost-effective drug therapies, and pharmaceutical benefit management, for more than 30 years. He currently serves on several pharmaceutical advisory boards and on the editorial advisory board of ODG/ODG Treatment publication from the Work Loss Data Institute.

He graduated from the University of Iowa with his BS in Pharmacy, and his MS from the University of Maryland.

Steven M. Moskowitz, MDDr. Moskowitz is a specialist in physical medicine and rehabilitation with clinical expertise in complex musculoskeletal and neurologic rehabilitation including spinal cord injury, multiple sclerosis and chronic pain. He provides overall medical supervision for Paradigm’s pain program.

After beginning his clinical practice in 1989, he worked at the Lahey Clinic in Burlington, MA for 16 years and currently practices at Mount Auburn Hospital in Cambridge, MA and the Life Care Center of Nashoba Valley, MA. He led efforts in a variety of case management models including catastrophic case management, high-risk acute care case management and workers’ compensation.

A consultant for medical staff peer review redesign for The Greeley Company from 2003 to 2006, Dr. Moskowitz has served on a number of committees, including the Greater Boston Chapter of the National Spinal Cord Injury Association, the Spinal Cord Injury Standards Committee of the Commission on Accreditation of Rehabilitation Facilities, and the Medical Advisory Committee of the New England Chapter of the National Multiple Sclerosis Society. He is a member of the American Academy of Pain Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American Pain Society.

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Dr. Moskowitz has worked with Paradigm Management Services since 1997 as a Paradigm Medical Director for catastrophic and chronic pain case management, and now serves as Senior Medical Director for Paradigm’s chronic pain program. He also was involved as a workers’ compensation utilization review physician.

Mark PewMark has worked in a variety of roles with PRIUM since 1989, with current responsibilities including educational outreach, product development and marketing. His current focus is to develop strategies for managing the overutilization of prescription drugs and the education of stakeholders. He created PRIUM’s Medical Intervention Program in 2003 and has since refined the program and created several other services to address the prescription drug epidemic. He has over 30 years of experience in building enterprise strategies for businesses in healthcare, finance, and technology including work at Equifax, ChoicePoint, CoreSpeed and MedicaView International. Considered a thought leader in workers’ compensation, Mark is regularly quoted in articles, written several articles and white papers, and from Feb 2012 thru June 2014 presented 159 times to 9,580 people in 31 states on best practices around the treatment of chronic pain. He is a member of the medical issues committee of International Association of Industrial Accident Boards and Commissions (IAIABC). Mark can be found at LinkedIn or on Twitter @RxProfessor.

Steve M. Pratt, CPCU, AU, ARM, SCLA, CMSPSteve Pratt is the Director of Worker’s Compensation at Berkley Southeast Insurance Company a WR Berkley Company where he is responsible for overseeing all aspects of the workers’ compensation claims line of business. He has 35 years of experience in the insurance industry, having held senior-level roles in the claims organizations of The Hartford, The Zenith, QBE of the Americas, CNA and Broadspire. Mr. Pratt consulted in the insurance claims environment in quality, reserving, narcotic prescription use and other areas. He also conducts ongoing leadership training in Ukraine. Mr. Pratt holds a number of professional designations, including Chartered Property Casualty Underwriting (CPCU), Senior Claim Law Associate (SCLA), Certified Medicare Secondary Payer (CMSP), Associates in Underwriting (AU) and Associate in Risk Management (ARM). Mr. Pratt has also earned his Master’s Degree in Organizational Management from the University of Phoenix.

Fran Provenzano, RN, BSN, CDMS, CCM, QRP, CLCP, MSCC, CMSPAs President and CEO of MSA Specialists, Fran has been on the cutting edge of the Medicare Secondary Payer Compliance and was the second professional in the Nation to receive MSCC certification. MSA Specialists is a national service provider of MSA Compliance for claims from New England to Hawaii. She serves as the lead Instructor to the University of Florida for the purpose of providing educational seminars around the nation. These seminars are to educate and train prospective MSA practitioners. Fran has held these seminars (under the UF’s direction) in several states and in an online format. These classes are preparation for national certification of new MSA practitioners. Through her involvement with the University of Florida and her leadership role in NAMSAP, Fran is a nationally recognized authority on MSAs, and a highly sought after speaker on the subject. She has presented at National nursing conferences, on a variety of subjects, since the mid-80’s. In addition, Fran has authored the MSA section of the Legal Nurse Consultant Textbook and has provided online training for NAMSAP (National Alliance of Medicare Set-Aside Professionals). Fran has served as Vice-President and currently remains a board member of NAMSAP. Fran received her Bachelor of Science in Nursing from the University of Tampa and holds credentials and certifications in the following areas; Certified Disability Management Specialist; Certified Case Manager, Qualified Rehabilitation Provider, Certified Life Care Planner, Medicare Set-Aside Consultant Certified, Certified Medicare Secondary Payer Professional.

James R. Raines, Esq.James R. Raines is a partner in the Baton Rouge office of Breazeale, Sachse & Wilson, L.L.P. and is a member of the firm’s recruiting committee. James practices in the areas of casualty, tort and insurance defense, with an emphasis on workers’ compensation matters on behalf of employers, insurers and self-insured funds.

Another major focus of his practice is on Medicare compliance and particularly the Medicare Secondary Payer Act. In 2013, James earned the designation of Certified Medicare Secondary Payer Professional from the Louisiana Association of Self Insured Employers. James also speaks regularly on issues related to the Medicare Secondary Payer Act.

James was also recently appointed to serve as a hearing officer in litigation involving a state licensing board. He has also handled matters involving mental health law, including interdictions, family law, including complex community property litigation, commercial litigation, premises liability, landlord/tenant law, property law and contested successions.

Michele E. Ready, Esq.Ms. Ready’s primary area of practice is insurance defense, workers’ compensation litigation, including an emphasis on Medicare Secondary Payer compliance. Ms. Ready also specializes in workers’ compensation appellate matters. She has lectured throughout the state of Florida on Medicare Secondary Payer compliance issues. She was invited to participate in panel discussions presented at the Florida Workers’ Compensation Institute 2010 and 2011 Conference in Orlando, Florida, as well as at the American Bar Association’s Standing Committee’s Legal Professional Liability 2010 conference in Scottsdale,

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Arizona. In 2013, Ms. Ready spoke on a national panel of experts at the annual education conference of NAMSAP in Baltimore, Maryland. Prior to joining the firm she worked in business management after obtaining a BA degree in Music with a minor in Marketing. In law school, she was a member of the Business Law Journal and the Florida Sports and & Entertainment Law Review.

Ms. Ready is “AV” rated by Martindale Hubbell (AV®, BV®, AV Preeminent® and BV Distinguished® are registered certification marks of Reed Elsevier Properties Inc., used under in accordance with the Martindale-Hubbell certification procedures, standards and policies.)

Ms. Ready is certified by the State of Florida to lecture and provide Florida Continuing Education credits to insurance adjusters. She has lectured on numerous topics, most recently Medicare Set-Asides and Mandatory Insurer Reporting Requirements under the MMSEA. She is a member of RIMS, Greater Miami Chapter, the National Alliance of Medicare Set-Aside Professionals (NAMSAP), and of Chamber South.

Ms. Ready graduated cum laude from University of Miami with her JD and completed her Bachelors summa cum laude from The Ohio State University.

Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSPAs Franco Signor’s Chief Legal Officer, Heather is responsible for leading corporate strategic and tactical legal initiatives. In her role, she works internally with staff and externally with clients to facilitate MSP Compliance, namely to provide compliance counseling on Conditional Payment Negotiations, Mandatory Insurer Reporting, Medicare Set-Asides, and all other areas within MSP Compliance. Heather is charged with the drafting and negotiating of corporate contracts, the definition and development of corporate policies and provides continuing counsel on all corporate legal matters.

Heather is a regularly published author and national speaker on MSP compliance. Her articles have been featured in publications such Risk & Insurance, workerscompensation.com, WorkCompWire and WorkComp Central. Prior to joining Franco Signor, Heather held previous roles as Corporate Counsel for both Helios and Gould & Lamb.

Heather has a Juris Doctorate degree from St. Thomas University School of Law and also an undergraduate degree in Political Science from The University of Central Florida. She is a member of the Florida Bar and holds the following certifications: Medicare Set-Aside Consultant Certified (MSCC), Certified HIPAA Privacy Expert (CHPE), Certified Litigation Management Professional (CLMP), and Certified Medicare Secondary Payer Professional (CMSP).

Thomas Spratt, CMSPWith more than 40 years of experience in the insurance industry, Thomas Spratt is an authority on issues related to Medicare compliance as to Workers’ Compensation and Liability claims. As Senior Vice President – Technical Operations, Tom is responsible for the Protocols Claims Management Consulting Group. He oversees assessment of clients’ Medicare compliance programs, training of claims staff and client settlement strategies for costly or complex cases involving both Workers’ Compensation and Liability. Tom is also conversant in Special Needs Trusts and their role in the settlement of high-exposure, disputed Workers’ Compensation and Liability matters. Tom developed a ground-breaking and widely emulated Medicare Set-Aside compliance program for a national carrier. He has spoken on this subject at numerous national insurance industry conferences. Tom’s expertise spans all state and federal statutory jurisdictions, as well as employer liability suits. Tom has a long record of active involvement in the insurance industry, serving on committees for the Workers’ Compensation Research Institute/WCRI, the Property Casualty Insurers Association of America/PCIAA and the Strategic Services on Unemployment and Workers’ Compensation/UWC.

Tom also serves on committees for the National Structured Settlement Trade Association and the National Alliance of Medicare Set-Aside Professionals. Tom currently chairs the Education committee for NAMSAP (National Alliance of Medicare Secondary Payer Professionals) and also serves on the faculty of the CMSP (Certified Medicare Secondary Payer designation program); it is the only program where both the law and allocations make up the curriculum.

Thomas Stanley, MSSC, CMSPThomas Stanley is the president of the Stanley Insurance Agency, Inc. Since 2002, the Agency has provided full service WC Medicare Set-aside consultation to a varied clientele. WCMSA services are a natural compliment to the settlement annuity services the Agency began providing in 1987. Mr. Stanley hold the MSSC and CMSP certifications. Recently, he was one of the first to complete the Masters in Structured Settlement Consulting program at the University of Notre Dame. Tom has an MBA in finance and economics. He is a native of Minnesota and now lives in Las Vegas, Nevada.

Kayla Tortorich, RN, BSN, MSCC, CMSPKayla Tortorich is the Vice President of Managed Care Programs for WellComp Managed Care Services. Kayla stewards the Medicare Secondary Payer/Medicaid compliance team; as well as a portion of the medical bill review, nurse bill audit business unit and the WellComp Call Center. Kayla participates in presentations empowering both the internal and external customers with managed care and Medicare compliance knowledge.

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Kayla earned a baccalaureate of science in nursing from Louisiana State University Medical Center and received a certification in Legal Nurse Consulting from this University. Kayla has been practicing in the field of Medicare Secondary Payer Compliance and is a Medicare Set Aside Certified Consultant and Certified Medicare Secondary Payer Professional. She is a national speaker regarding the topic.

Meredith Warner, MD, MBADr. Meredith Warner is a board certified Orthopedic surgeon, fellowship trained in complex foot and ankle reconstruction, practicing in Baton Rouge, Louisiana. Dr. Warner started her private practice Warner Orthopedics and Wellness In April 2013 and is an expert in general orthopedic medicine, care of the injured worker, the treatment of complex foot and ankle injuries and the non-operative treatment of the spine. Prior to arriving in Baton Rouge, she severed as a Major in the United States Air Force with two deployments; she served in Iraq and Afghanistan performing combat surgery. Dr. Warner also performed surgery on a disaster relief mission to Haiti in January 2010. Upon her arrival to Louisiana she entered into the executive MBA program at Louisiana State University and completed her degree in the winter of 2010. Dr. Warner is committed to offering her patients an accurate diagnosis and comprehensive treatment plan in order to get them back to the most functional and best life possible.

Dr. Meredith Warner graduated with honors from the Medical Scholars Program at the University of Delaware, and earned her medical degree from Thomas Jefferson University Medical School in Philadelphia, PA. She completed an internship in General Surgery and an Orthopedic surgery residency at Tulane University School of Medicine in New Orleans, LA, and her fellowship in foot and ankle reconstruction at University of Texas Medical Branch in Galveston, TX. She has trained extensively in spine intervention techniques. Her special interests are in the treatment of orthopedic issues, providing operative and non-operative treatment plans of orthopedic problems, including musculoskeletal pain such as chronic back, neck and foot pain, reconstructive surgery of the foot and ankle, arthritis, diabetic, hammer toe, bunion, wound care, work injuries, fitness and nutrition and osteoporosis issues.

Monica A. Williams, BSN, RN, CCM, CRRN, LNC, MSCC, CMSPMonica A. Williams is President of MWC Associates, LLC. She was formerly the National Catastrophic Program Manager for Cigna/Intracorp. She has over 20 years in case management services. She currently provides Medicare and Workers Compensation Consulting, medical cost projections, complex case reviews and is a registered Catastrophic Case Manager for the State of Georgia. She also consults for CMS submission, MSPRC compliance and assist with Life Care Plans for purpose of establishing needs for catastrophic or complex cases. She specializes in the analysis of Neurology, Multiple Trauma, Burns, Orthopedics and Preventive Medicine.

She is a Registered Nurse, Certified Case Manager, Certified Rehab Registered Nurse, Legal Nurse Consultant, Certified Medicare Set Aside Consultant and Certified Medicare Secondary Payer Consultant. She is a graduate of Jacksonville State University and has a Bachelor of Science Degree in Biology and Nursing.

Denise W. Wrenn, MSA, RN, CCM, CWCP, COHN-S, CMSP, ALNC, CLCPDenise W. Wrenn, occupational health consultant at Cleco Corporation headquartered in Pineville, Louisiana, is responsible for all facets of the workers’ compensation program. Wrenn oversees injury investigation, return-to-work requests, and case resolutions where she is liaison between third-party administrators, medical providers, attorneys, and injured employees. She ensures compliance with federal and state agencies relative to the safety, health, and wellbeing of employees. In addition, Wrenn develops programs and procedures to achieve compliance with corporate drug-and-alcohol testing, medical surveillance and safety programs.

Wrenn earned a Bachelor of Science at the University of Texas Health Science Center’s School of Nursing in San Antonio and a Master in Health Care Administration from Central Michigan State University. She holds Registered Nurse licensures in Louisiana and Texas. Wrenn maintains several professional certifications that include Workers’ Compensation Professional, Case Manager, Occupational Health Nurse-Specialist, Medicare Set Aside Professional, Advance Legal Nurse Consultant, and Certified Life Care Planner.

Kathleen Wyeth, JD, MSCC, CMSPKathleen Wyeth is the Medicare Specialist at Accident Fund Holdings, Inc., responsible for coordinating all Medicare compliance throughout the enterprise. She is co-author of the Michigan Chapter of The Complete Guide to Medicare Secondary Payer Compliance, published in October 2012. She was a presenter on Medicare topics at the National Workers’ Compensation Defense Network Fall Conference, 2012 and the Michigan Association of Justice Winter Conference 2013. Kathleen obtained her Juris Doctorate from the University of Detroit Mercy and has spent 13 years working broadly in the insurance industry.

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11th Annual Meeting & Educational Conference

Wednesday, September 30, 2015 8:00 am - 9:00 am

Top 10 Submitter Errors

Submitting an MSA to CMS can be a daunting task. This session will shed some light on this tedious undertaking and spell out some of the common

mistakes made during the process.

PanelistCarmen Bullard, Concierge Medical & Risk Consultants Company

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Medicare Set Asides and Top 10 Submitter Errors

Carmen Bullard BS, MSCC  

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DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

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Medicare requirements

What does the law say?

Pursuant to 42 U.S.C. §1395y(b)(2) and § 1862(b)(2)(A)(ii) of the Social Security Act, Medicare is precluded from paying for a beneficiary's medical expenses when payment "has been made or can reasonably be expected to be made under a workers' compensation plan, an automobile or liability insurance policy or plan (including a self‐insured plan), or under no‐fault insurance.”

www.cms.gov

What does Medicare require anyway?

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Medicare requirements

Recovery§ 411.24 Recovery of conditional payments.

(b) Right to initiate recovery. CMS may initiate recovery as soon as it learns that   payment has been made or could be made under workers' compensation, any liability or no‐fault insurance, or an employer group health plan. Federal law (42 U.S.C. § 1395y(b)) not only establishes that Medicare is a secondary payer to WC, but also that Medicare has a priority right of recovery over any other entity to the proceeds of any settlement. To the extent that Medicare has made any "conditional payments", Medicare will recover those payments pursuant to 42 C.F.R. § 411.47.Pursuant to 42 C.F.R. § 411.21, "conditional payments" are Medicare payments for services for which another payer is responsible, made either on the bases set forth in 42 C.F.R. § 411 subparts C through H, or because the intermediary or carrier did not know that the other coverage existed.

http://ecfr.gpoaccess.gov www.cms.gov

Medicare Requirements

Future Medical Payments – Workers CompensationThe burden of future medical expenses in WC cases may not be shifted to Medicare.42 C.F.R. § 411.46 and § 411.47 provide that Medicare's interest must be considered in WC settlements, when future medical expenses are a component of the settlement.Because Medicare does not pay for an individual WC related medical services when the individual receives a WC settlement that includes funds for future medical expenses, it is in the best interest of the individual to consider Medicare at the time of settlement. For this reason, CMS recommends that parties to a WC settlement set aside funds, otherwise known as Workers' Compensation Medicare Set‐aside Arrangements (WCMSAs) for all future medical services related to the WC injury or illness/disease that would otherwise be reimbursable by Medicare.

www.cms.gov

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Medicare Requirements

Future Medical Payments – LiabilitySubpart D—Limitations on Medicare Payment for Services Covered Under Liability or No‐Fault Insurance§ 411.50 General provisions.(c) Limitation on payment for services covered under no‐fault insurance. Except as provided under §§411.52 and 411.53 with respect to conditional payments. Medicare does not pay for the following:(1) Services for which payment has been made or can reasonably be expected to be made under automobile no‐fault insurance.(2) Services furnished on or after November 13, 1989 for which payment has been made or can reasonably be expected to be made under any no‐fault insurance other than automobile no‐fault.

http://ecfr.gpoaccess.gov

Medicare Requirements

Future Medical Payments – Liability§ 411.51 Beneficiary's responsibility with respect to no‐fault insurance.(a) The beneficiary is responsible for taking whatever action is necessary to obtain any payment that can reasonably be expected under no‐fault insurance.(b) Except as specified in §411.53, Medicare does not pay until the beneficiary has exhausted his or her remedies under no‐fault insurance.(c) Except as specified in §411.53, Medicare does not pay for services that would have been covered by the no‐fault insurance if the beneficiary had filed a proper claim.(d) However, if a claim is denied for reasons other than not being a proper claim, Medicare pays for the services if they are covered under Medicare.

http://ecfr.gpoaccess.gov

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Protecting Medicare from future medical payments:

Medicare Set Asides a vehicle for compliance.

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Is the process Voluntary?

The law requires that you must protect Medicare’s interest when settling however, how you do that is not mandated by law.

In Workers Compensation claims a Medicare Set Aside is the CMS (Centers for Medicare and Medicaid Services) recommended method for protecting Medicare against future medical payments.

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Do I have to get a MSA?

Law does not mandate that a MSA is required to settle a case.

With that said, a MSA is an excellent option for protecting Medicare’s interest in many cases.

Worker’s Compensation Cases

All other cases required to protect Medicare in the settlement (liability, no‐fault…) however, in these cases special care should be taken in choosing an allocator, as these cases have no required submission thresholds.

If the plaintiff/claimant is a beneficiary the safest option is to obtain a Medicare Set Aside.

What are all the memos about?

CMS has issued a total of 15 memos which were meant to guide the Medicare Set Aside process in Worker’s Compensation claims.

These memo’s give guidance to most of the issues that may arise when dealing with a MSA.  Including, medical care pricing, prescription drug pricing, rated ages, life expectancy, funding the MSA, calculations of settlements, submission guidelines… 

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When do MSA’s Need to Be Submitted?

The following guidelines apply specifically to Worker’s Compensation Cases:If the claimant/plaintiff is a current Medicare Beneficiary and the settlement amount is greater than $25,000, the MSA should be submitted for review.If the claimant/plaintiff has a “reasonable expectation” of enrollment in Medicare within 30 months of the settlement date and the settlement amount is greater than $250,000, the MSA should be submitted for review.Computing the Total Settlement Amount:The computation of the total settlement amount includes, but is not limited to, wages, attorney fees, all future medical expenses (including prescription drugs), and repayment of any Medicare conditional payments. Payout totals for all annuities to fund the above expenses should be used rather than cost or present values of any annuities. Also, any previously settled portion of the WC claim must be included in computing the total settlement amount. (Ref: 4/25/06 Memo)

www.cms.gov

When do MSA’s Need to Be Submitted?

Liability SettlementsThere are currently no CMS issued guidelines regarding review of MSA’s in cases other than Workers Compensation.Should I submit my Liability MSA?Not necessarily.  There are some offices that are reviewing liability MSA’s depending on current workload.  

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Where is the MSA reviewed?

There are 10 regional offices: Boston, New York, Philadelphia, Atlanta, Chicago, Dallas, Kansas, Denver, San Francisco and Seattle.

Currently 6 regional offices review MSA’s: Boston, Philadelphia, Chicago, Dallas, San Francisco, Seattle. 

16

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Development

What is development?If the RO needs additional information or documentation from the submitter in order to continue processing the WCMSA case, the submitter is notified with a development letter. When documentation is received and scanned at the COBC, the status of the case changes to “Development Received,” and the RO begins the review again. If a response is not received within the allotted time frame (i.e., 30 days for cases submitted to the COBC, 10 business days for cases submitted on the WCMSAP), the case is closed for lack of response. If a response is received after the case is closed, CMS will reopen the case but treat it as a new submission.www.cms.gov

Reasons for Development

Common Mistakes:

Did not include all of the necessary medical records.

Did not submit other necessary documentation (payment history, evidence for prescription usage or medical equipment usage, legal documentation)

Incorrect Information (social security number or address incorrect)

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CMS Top 10 List

19

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Error Helpful Hints

3. Insufficient proof of medications, dosages, and frequencies for the last two years of treatment. For example, the WCMSA proposal contains only: • A letter from the claimant or his attorney indicating the claimant is

currently not taking any medications for the work injury or has not taken medications related to the work injury in the last “x” years;

• A letter from the carrier or its attorney indicating that no payments were made for medications;

• Information regarding the names of medications and strength/dosages, yet missing frequency information.

• Please provide sufficient documentation in the form of legible, recently-dated pharmacy printouts or statements from all treating physicians specifying the medication name, strength/dosage, and frequency.

• If you believe the medications the claimant is taking are not related to the work injury, please send the medication information with any necessary explanation.

• If the claimant has used more than one pharmacy or has had multiple treating/prescribing physicians, ensure that all the physicians/pharmacies have been contacted and have provided medication information.

• Provide physician dispense records for cases where the treating physician is dispensing medications that do not appear on the carrier pharmacy printout history.

4. Carrier payments history is missing, undated, old, or incomplete. Examples include: • A carrier payment history containing medical payments only;

indemnity or expense payments only or containing no explanation; • A carrier payment history dated more than six months prior to the

date the case was submitted or reopened; • A statement that there is no payment history attached because the

claimant has not treated in the last two years.

• Submit an all-inclusive carrier payments history (containing all medical, indemnity, and expense payments made) dated within the last six months prior to submission or re-opening. The document must show all payments made by the carrier and include payment date, payee, date of service, and payment amount for at least the last two years of treatment. A payment history must be provided, even if the submitter is requesting that zero funds be set aside. If the carrier did not make any payments under one of the categories, the payment history should show “0” payments.

• If the carrier’s payment history typically does not show the run date, please provide a letter from the carrier or its attorney stating the run date.

• If the carrier made no payments for medical, indemnity, or expenses and did not set up settlement reserves for the claim, a letter from the carrier or its attorney explaining why there is no printable payment history is required.

Error Helpful Hints

5. Total settlement amount missing, unclear, or improperly computed.

• Submit gross total settlement amount as a single lifetime number. If annuities are involved, use the lifetime payout amounts in the total instead of annuity purchase prices, and include the annuity rate sheet to support your calculation. Include in the total all attorney fees, proposed set-aside amounts for medical services and/or prescription drugs, settlement payments of past medical expenses/liens, amounts for non-Medicare medical expenses, settlement payment of any Medicare conditional payments, amounts of previous settlements, any third party liability settlements and amounts of any waived or forgiven liens/expenses at settlement.

• References to attachments without stating a settlement number generally result in a development request. If you are unsure of the total amount, call the Workers' Compensation Review Contractor (WCRC) at 855-280-3550 for assistance in computing the number.

6. No response or insufficient response to development requests.

• Make sure each item on the CMS request letter is addressed timely, especially the items printed in ALL CAPS. Specific reply language may be necessary.

• Do not resubmit documents submitted previously unless you have confirmed they were not received. If you are unsure of what is needed, call the WCRC to see if what you are sending will be sufficient.

7. Proposed set-aside amount not clearly divided between medical services and prescription drug costs.

• The submitter must give a proposed lifetime (not annual) set-aside amount and should show clearly how much of the total figure is for medical services and how much is for prescription drugs. The WCMSA Reference Guide, Appendix 5 (Sample Submission) provides a helpful format.

• Confirm that the proposed amounts for medical services plus prescription drugs add up to the total proposed amount.

• Verify that any pricing charts are consistent with the amounts shown in your cover letter. • Confirm that the proposed amount is consistent with the court documents or that any differences

are explained. • If an annuity is involved, use lifetime payout amounts instead of annuity purchase prices and

include amount of proposed seed money/initial deposit.

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Error Helpful Hints

8. Submission of unnecessary, unrelated, or duplicate documents. Examples include: • Copies of CMS development letters and other letters; • Correspondence between the claimant’s medical provider and the

attorney showing the effort expended to obtain documents; • Invoices or subpoenas for medical records; • Notices concerning medical appointments; • Medical records of monthly visits during each of the last 15 years; • Additional copies of documents previously determined insufficient; • Court scheduling orders.

• Provide the items noted in the WCMSA Reference Guide, Appendix 5 (Sample Submission). You may send in whatever you believe is necessary and helpful and it will be reviewed; however, in most cases, the only medical records needed are the initial report of injury, records related to major surgeries, and medical records for the last two years of treatment for the work injury.

• If you are planning to send in over 200 pages of information or more than two years of medical records, you may call the WCRC to discuss whether this is needed.

• Do not resubmit previously submitted documents unless you have confirmed they were not received. If you are unsure what is needed, call the WCRC to discuss.

9. Incorrect references for a state that does not have a fee schedule. Please be aware that the following states do not have a fee schedule: Indiana, Iowa, Missouri, New Hampshire, New Jersey, and Virginia.

10. No rated age statement submitted confirming that all rated ages obtained on the claimant have been included.

Submit a rated age confirmation with the original proposal documents. Please be aware that CMS will not accept any variation or substitute wording for the rated age confirmation and it must be provided on the letterhead of a life insurance company or settlement broker (see CMS’ June 8, 2010 procedure memorandum ).

11. Incorrect pricing of drugs, e.g., quoting or using prices associated with re-packagers, expected tapering, etc.

Please review Sections 9.4.6.1 & 9.4.6.2 of the WCMSA Reference Guide for information on prescription drug pricing.

12. Multiple dates of injury, multiple body parts, body parts remaining open for medicals.

Please be sure to specify each date of injury being settled, all body parts/conditions associated with each date of injury, including body parts that are accepted or denied by the carrier, and whether any of the body parts/conditions are left open for medicals by the carrier. • We need a pay record for each date of injury or documentation that the payment record provided

includes/reflects each date of injury. • We need two years of medical records that reflect treatment for each body part being settled,

dated within six months of the date of submission or reopen date. • We need prescription records that reflect all prescription medication for each industrial condition,

including dose and frequency.

Remedies to Common Errors

Be Proactive – Do not submit MSA’s with missing information and double check all information for accuracy.

React Quickly – Speak with appropriate parties to obtain requested information and submit that information quickly, for a timely resolution to the submission error.

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11th Annual Meeting & Educational Conference

Wednesday, September 30, 2015 9:00 am - 10:00 am

Ethics in the MSP IndustryPanelists

Denis Juge, Juge, Napolitano, Guilbeau, Ruli & FriemanKayla Tortorich, WellComp Managed Care Services

Monica Williams, MWC Associates, LLC

With no clear laws guiding the settlement community on exactly how to protect Medicare’s interest as a secondary payer, the line is often blurred between right and wrong. Our panelists will discuss several real-world scenarios that will create a stimulating conversation and raise opposing

viewpoints on different methods of proper MSP compliance.

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2015 ANNUAL NAMSAP MEETING SEPTEMBER 30, 2015 – OCTOBER 2, 2015

NEW ORLEANS, LA

ETHICS IN MEDICARE SECONDARY PAYER COMPLIANCE

Denis Juge, JD, Attorney at LawKayla Tortorich, RN, BSN, MSCC, CMSPMonica Williams, BSN, RN, CCM, CRRN, LNC, MSCC, CMSP

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DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

3

4

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Panel Objectives

Exploration of Ethics and Professional Responsibility of the MSA Professional based on standards of practice

Legal and practitioner perspectiveDiscuss Guiding Principles

• Integrity• Fairness, Honesty & Due Care• Competence• Confidentiality• Professionalism• Compliance – Variance of standard of practice

amongst states

5

Integrity/Fairness, Honesty and Due Care

The MSP professional must exercise the utmost integritywhen providing MSA arrangements.

Having integrity means doing the right thing in a reliable way

Integrity literally means having "wholeness" of character

6

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Integrity/Fairness, Honesty and Due Care

Services should be rendered with professionalism, honesty and candor

MSP professional should not compromise these values for personal gain or advantage

Faithfulness to the obligation and duties they have to their clients and to upholding MSP compliance

7

Competence

Knowledge and experience is the cornerstone of our industry

What does the Medicare Set-aside Certified Consultant (MSCC) credential demonstrate?

Review of ICHCC qualification requirements Medicare Set Aside Certified Consultant qualification requirements

Other certification opportunities related to MSP

8

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Competence

Knowledge and experience is the cornerstone of our industry

MSP formal educational training among individuals who work in healthcare, legal representatives and claims adjusters

Certified professionals are expected to maintain current understanding of applicable state laws, claim procedures, CMS guidelines and Federal laws related to MSP

Commitment to continuing education

9

Competence

MSP formal educational training among individuals who work in healthcare, legal representatives and claims adjusters

Certified professionals are expected to maintain current understanding of applicable state laws, claim procedures, CMS guidelines and Federal laws related to MSP

Commitment to continuing education

10

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Confidentiality

MSP professionals are not to disclose confidential information to unauthorized persons without the express written consent of the source or pursuant to legal requirements or court orders

Confidentiality of both claimant and client information

11

Confidentiality

Changes in use of social security numbers, or portion of SSN, as an identifying information requirement

Non-disclosure and confidentiality agreements

HIPPA – When is it a legal requirement?

12

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Professionalism

Responsibility to maintain professionalism with parties involved in the MSP process

Examples: Professionalism tested and suggestions to address contentious scenarios [Opposing Counsel? CMS Representative?]

Courtesy, respect and dignity to peer professionals, claimants and clients

13

Compliance

MSP professional should comply with all material, federal and state laws and regulations

Discuss State vs. Federal Regulations What has CMS MSA Review Contractor

approved? State regulations upheld? Or overruled with Federal/CMS rules?

Compliance with Medicare allowable and non-allowable services

MSP compliance – Medicare maintaining secondary payer status where applicable

14

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Case Scenarios: Conflict of Interest

What to do?

Handling scenarios with potential conflict of interest Professional partners Employees Employer Associates Requests from clients and /or attorneys concerning MSA allocation

15

Case Scenarios

Review of actual case scenarios addressing the core components of Ethics in the MSP Profession

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Ethics

Integrity

Fairness, Honesty & Due 

Care

Competence

Confidentiality

Professionalism

Compliance

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17

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11th Annual Meeting & Educational Conference

Wednesday, September 30, 2015 10:30 am - 11:30 am

MSP Compliance Situational Case StudyPanelists

Fran Provenzano, Medicare Set-Aside Specialists, Inc. Tom Spratt, Protocols

Tom Stanley, Stanley Insurance Agency, Inc.

Proper MSP compliance can be a tricky undertaking. Without a proper foundation, there are many pitfalls that can lead the practitioner astray.

This case study will review a scenario from start to finish while addressing many aspects of MSP compliance along the way.

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MSP Compliance in Situational Case Study

Tom Spratt CMSPFran Provenzano, RN

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

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Case Study- 1

• John Bargain sustained a low back injury which occurred while lifting a 70 pound box of office supplies. It was reported timely and the employee sought immediate treatment. The initial diagnosis of a lumbar strain evolved into a likely ruptured disc at L4-5. After 4 months of conservative treatment with little improvement. Mr. Bargain reported a pain level of 7/10. A single level laminectomy was performed.

Case Study-1

• Following surgery, Mr. Bargain reported minimal improvement in his pain level 6-7/10 which resulted in an ongoing regimen of opioids which have been increasing as time goes on. Mr. Bargain’s laboratory studies documented elevated liver enzymes. Mr. Bargain now 2 yrs. post-surgery has applied for Social Security Disability Insurance/SSDI and has been accepted.

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Case Study-1

• Mr. Bargain is 58 years old and is now represented by an Atty. Best. Mr. Bargain’s position with Jones Office Supplies is in the Stock department and involves lifting of 40-60 pounds on a frequent basis. The physical demands suggest RTW for his employer is unlikely. The employer has decided that settlement might be the best route for all. Their carrier suggested an MSA since the size of the settlement is unclear, an MSA was ordered.

Case Study-1

• When the WCMSA was received, the employer was surprised to see how large the projected costs were as they were not paying at such high levels. In review of the wcmsa, an SCS was included which added $165,000 to the MSA. When the employer asked why such procedures and associated costs were included since the carrier were unaware of an SCS being proposed, they were told the PCP had indicated “John might benefit from an SCS” some 1 ½ yrs. ago in an office note and that would likely prompt CMS to require funding, if the case was submitted.

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Case Study-1

• The MSA provider did indicate that since it was 1 ½ yrs. ago and CMS only requires the last 2 yrs. of medical, if the settlement effort was postponed another 6 months or so, the note would drop out and no SCS funding would be needed. Based on this information, as the MSA provider, are you comfortable with the proposed approach?

Case Study-1

• Would you consider digging deeper and ask the Clt. atty. to clarify what interest, if any, his client might have in an SCS or do you think ‘poking the bear’ can lead to untoward results.

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Case Study-1

• If you decided to seek clarification from his atty., how would you assess these answers?

• What if you were told John had a bad experience with the laminectomy and told his atty. he wouldn’t have any other procedures?

Case Study-1

• If you decide to seek clarification from his attorney how would you assess these answers?

• What if John responded and said he did not know what an SCS was but could ask his Dr. to explain?

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Case Study-1

• If you decide to seek clarification from his attorney how would you assess these answers?

• What if Mr. Bargain said he was thinking about it?

Case Study - 2

• Employer/carrier sets up an IME as they feel the level of care being offered is excessive. After the exam, they are surprised to see the IME has indicated the pain levels may be attributable to failed shoulder surgeries and a total shoulder replacement could alleviate much of the pain.

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Case Study-2

• The total shoulder was included within the MSA Allocation. The employer/carrier request the total shoulder be removed.

• Pain relief is with OTC medications, only.

Case Study-2

• The employer/carrier is close to settlement, they feel the Clt. won’t improve with any treatment and have asked the MSA provider if the IME needs to be considered if an Allocation/MSA is sought?

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Case Study-2

• The MSA provider advised that CMS does not consider an IME part of the medical record thus it does not have to be included in the records submitted nor allocated for.

Case Study-2

• Expectation settlement below $250K so CMS would not review it in any case and no meds need be provided.

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Case Study- 3

• Employer/carrier has agreed to settle the case at the same time as the Liability matter and fund the MSA as part of that. The clt. has had a laminectomy which was somewhat successful, his pain level is being managed somewhat but he is sedentary and feels the surgery was unsuccessful.

Case Study-3

• . An MSA has been completed , it does not contemplate surgery as there are no indications from the Ortho PCP it needs to be done.

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Case Study-3

• Clt. also treats with a Neuro and as part of the ongoing Liability litigation , he was deposed. He volunteered that he felt nerve damage continues which results in increased pain and a fusion may be needed to alleviate the ongoing nerve damage.

Case Study-3

• The employer/carrier asks if this information would need to be provided to CMS and if a fusion needs to be added to the MSA?

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Ethics

• Thank you for your participation

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11th Annual Meeting & Educational Conference

Wednesday, September 30, 2015 1:15 pm - 2:30 pm

Perspectives on MSP CompliancePanelists

Steve Pratt, Berkley Southeast Insurance Company Kathleen Wyeth, Accident Fund Holdings, Inc.

The MSP compliance industry has soared over the past decade. The pace is fast and it is often easy for a practitioner to lose sight of how

their body of work affects the end user. You will not want to miss this opportunity to hear our panelists discuss their views on the MSP

compliance industry from the carrier perspective.

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Perspectives on MSP Compliance

Kathleen Wyeth JD, MSCC, CMSP

Stephen Pratt CPCU SCLA CMSP ARM AU

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

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Introduction and Overview

• The MSP historical perspective ‐ what could we be doing better?

• MSAs – what is the exposure picture?

• Vendor or Partner

• Where is the industry going?

MSP Historical PerspectiveWhat could we be doing better?

Consistency among the 3 areas of compliance

• Sec. 111 – are the same diagnostic codes reflected in the MSA and paid for in conditional payments?

• Conditional Payments – your legal obligation extends to all diagnoses reflected in the settlement agreement

• MSAs – are you referencing all the diagnostic codes reflected in Sec 111 reporting

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MSP Historical PerspectiveWhat could we be doing better?

Pay attention to settlement language

• Don’t make submission of an MSA a requirement if it is not possible

• Look for contradictory language in the MSA detail and settlement language – do the conditions match?

• Every condition mentioned in the settlement is a potential CP

• Saying you considered Medicare’s interests does not mean you did

MSAs

Let’s review…

• What is the legal obligation? 

• When should an MSA be obtained?

• What are the possible consequences of not funding an MSA?

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MSAs

MSA Considerations

• MSA value should not drive medical management ‐ be proactive

• MSA should not be a surprise ‐ get medical records

• To settle or not to settle

Should the MSA be funded via annuity?

Benefit of professional administration?

Vendor or PartnerHow do we look at Service Providers?

Vendor Relationship

• Proactive approach

• How do carriers view MSA provider types?

• Boundaries/Ethical decisions come into play

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Where is the industry going?

Compliance and Process

• CMS recovery contractor switching to the CRC

• Greater scrutiny – CMS may actually begin using that Sec. 111 data

• More Claimants denied Medicare coverage

Thoughts on legislative initiatives

• Recent Senate and Congressional Bills – status?

• Effect on client/vendor relationship

Workers’ Compensation rates

Educational v Nuisance

Q&A

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11th Annual Meeting & Educational Conference

Wednesday, September 30, 2015 3:00 pm - 4:00 pm

Applying the Science of Evidence Based Medicine Guidelines to Fusions for Injured Workers

PanelistMarjorie Eskay-Auerbach, SpineCare and Forensic Medicine, PLLC

NAMSAP continues to promote and endorse Evidenced Based Medicine (EBM) guidelines as a more effective and efficient means of projecting

future medical needs. Our speaker will address the science behind EBM guidelines, and more specifically, how to apply these guidelines

to spinal fusions.

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9/22/2015

1

Indications for Lumbar Fusion and EBM

Marjorie Eskay-Auerbach, MD, JD

meamd@mindspring.com

520-731-9137

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

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9/22/2015

2

DISCLOSURES

• Contributing Editor– AMA Guides to the Evaluation of Permanent Impairment, 6th Ed.

• Other AMA Publications– AMA Guides to the Evaluation of Disease and Injury Causation, 2nd Ed.

– AMA Guides to the Evaluation of Workability and RTW– Royalties – AMA pubs related to Guides 6th

• Reviewer– ODG– ACOEM

Overview

• History of LBP

• Evidence‐Based Medicine (briefly)

• “Discogenic” pain and DDD

• Lumbar fusion – indications

• Lumbar fusion – outside indications

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9/22/2015

3

“Backache”

• Edwin Smith papyrus from 1,500 BC ends in the middle of a description of an acute back strain

• Degenerative changes have been found in the earliest human remains (Neandertal man)

Allan DB, Waddell G, An historical perspective on low back pain and disability, Acta Orthop Scand Suppl. 1989;234:1‐23

19th Century Approach to LBP

• Idea that back pain came from the spine and was related to trauma

• The pathology of “spinal irritation” was never demonstrated and the diagnosis disappeared, but the idea that the spine could be  a source of pain and that it must be irritable remain.

Allan DB, Waddell G, An historical perspective on low back pain and disability, Acta Orthop Scand Suppl. 1989;234:1‐23

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9/22/2015

4

Spinal Pain

• First attributed to injury or trauma in the Victorian era, a diagnosis of “railway spine,” attributed to the excessive speed achieved by steam engine trains.

• This occurred in parallel with the rise of the worker’s compensation system in England

Allan DB, Waddell G, An historical perspective on low back pain and disability, Acta Orthop Scand Suppl. 1989;234:1‐23

Industrial Revolution

• The industrial revolution and the building of railways led to serious injuries: only then did other cases of back pain begin to be blamed on trauma

Allan DB, Waddell G, An historical perspective on low back pain and disability, Acta Orthop Scand Suppl. 1989;234:1‐23

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9/22/2015

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Application of Orthopedic Principles

• 1900 – two to six weeks strict bedrest for acute LS pain (Bradford & Lovett 1900)

• Contrary to previous recommendations of mobilization, the notion that LBP and sciatica were due to traumatic inflammation gained ground 

• CLBP would develop if primary injury was not treated properly with rest (Love 1938)

Allan DB, Waddell G, An historical perspective on low back pain and disability, Acta Orthop Scand Suppl. 1989;234:1‐23

Back Pain was Medicalized

• Back pain became a disease, sufferer was a patient

• Rest removed the patient from everyday life and involved disability. 

Allan DB, Waddell G, An historical perspective on low back pain and disability, Acta Orthop Scand Suppl. 1989;234:1‐23

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Evidence‐Based Medicine

• The reliance on EBM has led to more rigorous assessment of scientific papers and publication of  of systematic reviews. 

• Systematic reviews assemble the evidence from previously published source papers which are graded for methodological quality according to preset criteria

Adams M, Bogduk N, Burton K, Dolan P, The Biomechanics of Back Pain, Third Edition, Elsevier, 2013  pg 54

Evidence‐Based Conclusions

• There is a hierarchy of scientific information. 

• Systematic reviews are the most highly regarded indicators in determining the strength of medical evidence.

• An evidence‐based conclusion is objective and should be reproducible 

http://www.lawjournalnewsletters.com/issues/ljn_medlaw/30_7/news/Evidence‐Based‐Medicine‐157968‐1.html

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Keeping Current

• Evidence‐based medicine: the integration of individual clinical expertise with the best available evidence from systematic research, as well as patient values and expectations.

• The best evidence is not static but, rather, changes when better evidence becomes available.

– Textbooks are often outdated.

– Physicians are often too busy to read current published research. 

New Horizons Symposium Papers   What Is Evidence‐Based Medicine and Why Should I Care?   Dean R Hess PhD RRT FAARC   Respiratory Care  July 2004 Vol 49 No.7

Best Evidence

New Horizons Symposium Papers   What Is Evidence‐Based Medicine and Why Should I Care?   Dean R Hess PhD RRT FAARC   Respiratory Care  July 2004 Vol 49 No.7

The best evidence can be found by identifying a systematic review or evidence‐based clinical practice guidelines .

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Is Lumbar Fusion Indicated for LBP?

• Lumbar fusion is intended to alleviate pain caused by the intervertebral disc– Degenerative disc disease– Discogenic pain

• Assumptions– The intervertebral disc is a source of pain

– Degenerative changes on MRI cause pain

Does DDD Explain LBP??

• Epidemiology of disc degeneration and associated pathology DO NOT explain symptoms of LBP and disability 

– Pathology on MRI has shown little relationship to sxs or disability

– Studies have failed to show that the appearance of degenerative changes could be used to predict subsequent development or worsening of symptoms.

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Changing Views

Battie, et al., The Twin Spine Study: Contributions to a changing view of disc degeneration The Spine Journal 2009; 9: 47-59

Discogenic LBP

CONCLUSION: Suspected discogenic pain, despite its extensive affirmation in the literature and enormous resources regularly devoted to it, currently lacks clear diagnostic criteria and uniform treatment or terminology

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One More Consideration….

How can we decide if LUMBAR FUSION is indicated?? 

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Objective vs. Subjective ? 

• Instability

– Flexion/extension x‐rays

• Radiculopathy

• Back pain

– ?discogenic pain

– Degenerative                     disc disease

Resources

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Lumbar Fusion is Recommended for:

• Unstable fracture, dislocation

• Acute SCI with post‐traumatic instability

• Spinal infections with resultant instability

• Scoliosis, Scheuermannn’s kyphosis

• Tumors

Spondylolisthesis

• Recommended as an option for 

– symptomatic isthmic or degenerative spondylolisthesis with instability; and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis, 

– with corroborating physical findings and imaging

– after failure of non‐operative treatment

(Washington, 2009) (Weinstein –SPORT, 2007), (Deyo –NEJM, 2007) (Jacobs, 2013), (Resnick, 2014)

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Fusion and Degenerative Spondylolisthesis 

Patients with degenerative spondylolisthesis who undergo laminectomy and fusion showed substantially greater improvement in pain and function during a period of 2 years than patients treated non‐surgically. (Weinstein‐SPORT, 2007) (Deyo‐NEJM, 2007) For degenerative lumbar spondylolisthesis, spinal fusion may lead to a better clinical outcome than decompression alone. (Martin, 2007) 

FLEXION                          EXTENSION

Fusion and Isthmic Spondylolisthesis

• Posterolateral fusion in adult lumbar isthmic spondylolisthesis 

– modestly improved long‐term outcome compared with a 1‐year exercise program.

– At long‐term follow‐up, pain and functional disability were significantly better than before treatment in instrumented and non‐instrumented 

– no significant differences between instrumented and non‐instrumented patients. (Ekman, 2005)

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Isthmic Spondylolisthesis 

SPONDYLOLYSIS SPONDYLOLISTHESIS

But….

• A systematic review of observational studies (retrospective) failed to find a clear association of isthmic spondylolisthesis with low back pain, raising questions regarding use of lumbar fusion to treat low back pain with isthmic spondylolisthesis in the absence of documented instability or radiculopathy. (Andrade, 2015)

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Is Lumbar Fusion Indicated for LBP?

• Lumbar fusion is intended to alleviate pain caused by the intervertebral disc– Degenerative disc disease– Discogenic pain

• Assumptions– The intervertebral disc is a source of pain

– Degenerative changes on MRI cause pain

• There is limited scientific evidence about the long‐term effectiveness of fusion for degenerative disc disease compared with natural history, placebo, or conservative treatment. (Gibson‐Cochrane, 2000) (Savolainen, 1998) (Wetzel, 2001) (Molinari, 2001) (Bigos, 1999) (Washington, 1995) (DeBarard‐Spine, 2001) (Fritzell‐Spine, 2001) (Fritzell‐Spine, 2002) (Deyo‐NEJM, 2004) (Gibson‐Cochrane/Spine, 2005) (Soegaard, 2005) (Glassman, 2006) (Atlas, 2006) (Resnick, 2005) (Fritzell, 2004) (Airaksinen, 2006)

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Fusion vs. Other Rx for DDD, NSLBP

Treatment Outcome Study

RCTsCognitive intervention + Exercise

Fusion DOES NOT afford a better outcome

Brox, 2010Keller 2004Fairbank, 2005Mannion 2013Mannion 2014

Systematic Reviews:Structured cognitive‐behavioral interventions + exercise

Fusion IS NOT more effective Mirza, 2007Gibson, 2005Andrate, 2013Jacobs, 2013

Systematic Review  Improvement in pain and function Phillips, 2013

Phillips, 2013

• One systematic review suggested improvements in pain and function associated with fusion to treat CLBP; however, the analysis included multiple types of studies (fusion vs. non‐operative treatment, comparisons of surgical treatments) and variable study designs (prospective and retrospective, randomized and non‐randomized, and some studies with substantial risk of bias)

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Deyo, 2009• In contrast to these results, recent studies document a 220% increase in lumbar spinal fusion surgery rates, and without demonstrated improvements in patient outcomes or disability rates. 

Yee, 2015

• A recent 13 state analysis found that workers were more likely to undergo low back surgery in locations with higher concentrations of orthopedic surgeons and neurosurgeons and in areas where doctors receive higher surgical reimbursements. 

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Medical Necessity

UR

• A study on improving quality through identifying inappropriate care found that use of guideline‐based Utilization Review (UR) protocols resulted in a denial rate for lumbar fusion 59 times the denial rates using non‐guideline based UR. (Wickizer, 2004) 

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RECOMMENDED CONDITIONS

• Spondylolisthesis– Isthmic

– Degenerative

• SCI/ Fracture

• Disc herniation with symptomatic radiculopathy undergoing 3rd decompression

• Revision of pseudoarthrosis

• Unstable fracture; dislocation

• Spinal infections, tumors

Other Guidelines 

• European Guidelines

• ECRI health technology assessment 

• AAOS, NASS, AANS, CNS, and SAS issued a joint statement to BlueCross recommending patient selection criteria for lumbar fusion in degenerative disc disease. The criteria included at least one year of physical and cognitive therapy, inflammatory endplate changes (i.e., Modic changes), moderate to severe disc space collapse, absence of significant psychological comorbidities (e.g. depression, somatization disorder), and absence of litigation or compensation issues.

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Other Guidelines

• AANS/NASS Guidelines, lumbar fusion is recommended as a treatment for carefully selected patients with disabling low back pain due to one‐ or two‐level degenerative disc disease after failure of an appropriate period of conservative care. 

• This recommendation was, in part, based on one study that included a lack of standardization of conservative care in the control group. At the time of the 2‐year follow up in that study, it appeared that pain had significantly increased in the surgical group from year 1 to 2. 

• In addition, there remains no direction regarding how to define the “carefully selected patient.” (Resnick, 2005) (Fritzell, 2004) 

Patient Selection

• A systematic review of the accuracy of tests for patient selection concluded that “no subset of patients with chronic low back pain could be identified for whom spinal fusion is a predictable and effective treatment.”

Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2013 Feb;13(2):99‐109. doi: 10.1016/j.spinee.2012.10.001.  1b

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• There is a lack of consensus among surgeons on the use of predictive tests for spinal fusion

• Prognostic patient factors were not consistently incorporated in treatment strategy

• Clinical decision making for spinal fusion for low back pain does not have a uniform evidence base in practice

Predictive Tests

• A systematic review of the accuracy of tests for patient selection concluded that “no subset of patients with chronic low back pain could be identified for whom spinal fusion is a predictable and effective treatment.”

Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2013 Feb;13(2):99‐109. doi: 10.1016/j.spinee.2012.10.001.  1b

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Not Recommended:

• Not recommended in workers’ compensation patients for degenerative disc disease (DDD), disc herniation, spinal stenosis without degenerative spondylolisthesis or instability, or nonspecific low back pain, due to lack of evidence or risk exceeding benefit. 

– Imaging studies do not predict back pain

– Discogenic pain is not well‐understood.

Adjacent Segment Degeneration/ Disease

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Adjacent Segment Degeneration/ Disease

• Back pain…. – History of LBP prior to first surgery

– Failure to improve after surgery

• Are there objective findings of disease?– Spinal stenosis– Radiculopathy– Instability

• There is a lack of consensus among surgeons on the use of predictive tests for spinal fusion

• Prognostic patient factors were not consistently incorporated in treatment strategy

• Clinical decision making for spinal fusion for low back pain does not have a uniform evidence base in practice

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Surgeons Recommendations

• >30%  would operate on 3 or more levels

• 53%  would operate on obese patients

• 24% would operate on morbidly obese pts.

• 41% would operate on smokers

• despite evidence of poor outcomes in these surgical groups. 

Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2013 Feb;13(2):99‐109. doi: 10.1016/j.spinee.2012.10.001.  1b

• There is a lack of consensus among surgeons on the use of predictive tests for spinal fusion

• Prognostic patient factors were not consistently incorporated in treatment strategy

• Clinical decision making for spinal fusion for low back pain does not have a uniform evidence base in practice

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Lumbar Fusion in WC

• Patient outcomes may have other confounding variables; there is evidence of poorer outcomes in subgroups of patients who were receiving compensation or involved in litigation  (Fritzell, 2001; Harris, 2005; Maghout‐Jurati, 2006; Atlas, 2006; Gum, 2013; Anderson, 2015)

• Utilization is much higher in this group despite poorer outcomes!!! (Texas, 2001; NCCI, 2006) – In WA, most frequent cause of death in post‐fusion pts was opioid overdose

Outcomes

Washington

• 67.7%  ‐ increased pain

• 55.8% ‐ no improvement in QOL

• 23% ‐additional surgery

• 21% ‐ death/narcotics

Ohio

• 90%‐ continued to take narcotics

• 76% continued opioid use at 2 years with 41% increase

• 27% needed another surgery

Franklin, 1994; Maghout‐Jurati, 2006, Nguyen, 2007, Nguyen, 2011

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Take Home:

• Not recommended in workers’ compensation patients for degenerative disc disease (DDD), disc herniation, spinal stenosis without instability, or nonspecific low back pain, due to lack of evidence or risk exceeding benefit. 

– Imaging studies do not predict back pain

– Discogenic pain is not well‐understood

– There is no consensus on predictive tests

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11th Annual Meeting & Educational Conference

Wednesday, September 30, 2015 4:00 pm - 5:00 pm

Affordable Care Act and Its Effect on MSAs

Panelists Patrick Hindert, S2KM Limited 

Ann Koerner, National Care Advisors

President Barack Obama signed the Affordable Care Act (ACA) into law in 2010. This controversial new healthcare law provides access to healthcare for millions of Americans that could not otherwise have

obtained coverage. Our panelists will explain the intricacies of this new law as well as the effects the ACA has on the cost of a claimant’s future

medical needs.

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Patrick J. Hindert, J.D.

Managing Director S2KM Limited

Patrick@s2km.com // (513) 899-2100

Ann Koerner, RN, BSN, CRRN President

National Care Advisors annkoerner@nationalcareadvisors.com

(614) 325-4269

NAMSAP 2015 ANNUAL CONFERENCE PRESENTATION OUTLINE

September 30, 2015

TITLE: “How the ACA Impacts Medicare, Medicare Compliance and MSAs”

Presented by Patrick Hindert and Ann Koerner

Introduction

Background and roles of Presenters Presentation Scope and Objectives

Commentators' Views – Scott Solkoff

"The ACA is a big new law that includes a mass of new statutes, state and federal regulations, court decisions, and variances that differ from state to state and county to county. Trained professionals, as well as consumers, will be challenged to understand and navigate this new system."

Commentators' Views – Alfred Chiplin, Jr. and Bethany Lilly

"The ACA is a vast experiment in paying for high-quality health care while preserving the Medicare program and expanding access to health care for other population segments. Implementation will be a tough, but doable challenge so long as we 'let the tools of the ACA work'. "

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Commentators' Views – Jessica Smyth

"How does the ACA change the guidelines for Medicare Set-Aside (MSA) preparation and the regulations for conditional payment reimbursement and Section 111 reporting? The short answer to this question is: not at all."

"The conclusion that CMS may heighten MSP enforcement as a result of the ACA remains to be seen. The situation as it exists now can be compared to an earthquake; the claims industry is anticipating the aftershock."

ACA Overview

Two laws enacted March 2010 906 pages of legislation 1764 pages of IRS regulations Over 24,000 pages of federal regulations 2 landmark Supreme Court cases

"New Definition" of Health Insurance

"Old definition" of health insurance policies: o Annual and lifetime limits, o No “medical loss ratio” to control administrative expenses and profits o Limited or no coverage for people with disabilities or pre-existing

conditions o Restrictions for children under parental policies o Limited preventive care coverage, and o Additional restrictions based on doctor choice or emergency room access.

ACA health insurance policies now must include all these features.

ACA and Medicare

ACA does not replace or terminate Medicare coverage. Medicare remains a single-payer system run by the federal government. Medicare meets ACA's health insurance coverage requirements. Selling a marketplace plan to a Medicare recipient is illegal. ACA does have coverage requirements that do affect Medicare. Health insurance exchanges do not affect Medicare coverage or choices.

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ACA-related Benefits for Medicare Recipients

Coverage for annual wellness visits; Elimination of cost-sharing for most preventative services; Increased consumer protections to Medicare Advantage (or Medicare Part C)

benefit plans; Increased coverage for prescription medications and preventive care; Expanded coverage for preventive services without a deductible or Part B

coinsurance Rewards for health care providers for enhancing services; Discounts and additional coverage to make Part D Medicare prescription drug

coverage more affordable; Gradually closing of the “donut hole” Extends the Medicare trust fund to at least 2029

Additional ACA Cost-containment Programs (Chiplin and Lilly)

Patient-Centered Medical Home – this is not likely to be fully funded o Purpose: to “redesign the health care delivery system to provide targeted,

accessible, continuous and coordinated, family-centered care to high-need populations.”

o To qualify: participant must be enrolled in Medicare Parts A and Part B and have at least one eligible chronic disease as defined by CMS.

o Currently being tested in CMS-designed demonstration models. Medicare Shared Savings Program – this is moving forward

o Purpose: "to promote accountability for a defined patient population, coordinate items and services under traditional Medicare Parts A and B, and encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery."

o Under the MSSP, groups of providers and suppliers that meet criteria defined by the Department of Health and Human Services (HHS) can work together to manage and coordinate care for Medicare fee-for-service beneficiaries through Accountable Care Organizations (ACOs).

o ACOs will be eligible to share cost savings if they meet HHS-defined quality performance standards.

The Independent Payment Advisory Board

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o A 15-member board of health care experts appointed by the President o Mission: to develop recommendations to "reduce the per capita rate of

growth in Medicare spending.” o Cannot make recommendations "to ration health care, raise revenues,

raise Medicare beneficiary premiums, increase Medicare beneficiary cost-sharing (including deductibles, coinsurance, and copayments), or otherwise restrict benefits or modify eligibility criteria.”

o IPAB reports will be submitted to MedPAC, HHS, the President and Congress.

o Reports will explain each recommendation and include both a legislative proposal and a CMS actuarial opinion.

o HHS will adopt IPAB recommendations unless Congress votes to prevent implementation.

Quality Review Mechanisms - restrict payments for services and procedures that do not meet care standards:

o Incentive payments for hospitals. o Limiting payment for hospital-acquired conditions. o National strategy to improve health care quality. o Interagency working group on healthcare quality. o Quality measurement development. o Health information technology. o Data collection to reduce health care disparities. o The Center for Medicare and Medicaid Innovation. o Preventive services.

ACA and Medicare Compliance

ACA does not explicitly address MSAs, conditional payment reimbursement, or Section 111 reporting.

ACA and MSP Act share a common objective - preserve fiscal integrity of Medicare Trust Fund.

ACA extends Medicare trust fund to at least 2029 ACA includes cost-containment programs to reduce future Medicare costs.

Potential Future Impact of ACA on MSP Enforcement (Smythe)

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Will the ACA increase enforcement of Section 111 reporting and conditional payment reimbursement?

ACA has competing purposes o Fiscal preservation of the Medicare trust fund, o Reduction of Medicare spending, o No annual lifetime limits on health care, o Guaranteed issue of health care coverage, and o No denial for preexisting conditions.

ACA has many provisions designed to identify and prevent fraud. o Enhanced screening of medical providers and suppliers, o Stronger civil and monetary penalties on providers that commit fraud, and o New penalties for submission of false data and false claims for payment.

ACA provides the DOJ and the OIG with greater access to CMS databases. ACA expands Medicare’s Fee-for-Service RAC program to Medicaid, Medicare

Advantage (Part C), and Medicare drug benefit (Part D) programs.

Does the ACA Eliminate the Need for MSAs? (Smythe)

Argument: o The ACA guarantees medical coverage and there are no denials for

coverage based upon preexisting conditions, o The workers’ compensation, or liability, claimant may use ACA coverage

to fund future medicals. o Therefore, an MSA in a workers’ compensation or liability claim may not

be necessary. Counter Argument: It is illegal for a Medicare beneficiary to be sold a

marketplace plan o Therefore, the ACA would not assume future medical coverage in

situations involving settlement of claims with Medicare beneficiaries o An MSA designed to protect Medicare’s future interests still will be

necessary. Current CMS WCMSA Reference Guide – 1-5-2015, Section 4.1.3 states that a WCMSA is recommended regardless of access to private health insurance, VA, Medicare Advantage or other coverage.

Conclusion: the ACA neither addresses nor changes MSA guidelines.

Collateral Source Rule

Background

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o The common law collateral source rule was first recognized in U.S. case law in 1884.

o Incorporated into Section 920A of the Restatement (Second) of Torts. o It allows a judge to exclude collateral compensation as evidence during

trial and when calculating damages. o As a result, some plaintiffs who possess health insurance historically have

been able to recover twice for medical expenses related to their injuries - from their insurer and from the tortfeasor.

Tort Reform o Because the traditional collateral source rule appears to overcompensate

plaintiffs, tort reform advocates (generally personal injury defendants and their insurers) have targeted and opposed it.

o As a result, 39 states have modified the collateral source rule from its common law (Restatement) form including six states (Alaska; Connecticut; Florida; Michigan; Minnesota; New York) which have abolished it completely.

o Eleven states (Arkansas; Louisiana; Mississippi; New Mexico; North Carolina; South Carolina; Texas; Vermont; Virginia; West Virginia; Wyoming) retain the rule in its unmodified form including states where courts have ruled legislation attempting to abolish the collateral source rule to be unconstitutional.

Subrogation o In addition to tort reform, the increasing use of subrogation by insurers has

affected the collateral source rule in personal injury cases by allowing the insurer to assert the rights of an insured plaintiff against the defendant and/or its liability insurer and thereby seek repayment after the plaintiff has received an award or settlement.

o Subrogation negates the collateral source rule's double-recovery effect because the plaintiff receives damages which exclude the collateral insurance payments and the defendant pays the full measure of damages to the plaintiff and the insurer.

ACA and the Collateral Source Rule

How the ACA will impact the collateral source rule is the subject of debate and litigation between defendants and plaintiffs.

It will also impact the work product of MSA professionals.

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Prior to enactment of the ACA, most seriously injured plaintiffs could not obtain ongoing health insurance as a result of the "pre-existing condition" related to their injury.

Because of the ACA's individual mandate and elimination of pre-existing condition restrictions, some defendants and commentators argue that plaintiffs' recoveries for future medical expenses in personal injury cases should now be restricted to the ACA’s annual maximum out-of-pocket limit plus the current cost of purchasing medical insurance.

Plaintiff attorneys and other commentators maintain the ACA has minimal effect on the collateral source rule relating to healthcare damages in tort actions despite undermining some of its justifications.

Key issue to be litigated: "whether it remains fair to continue to force the fiction upon the jury that future medical expenses projected by a plaintiff’s life care plan will be paid 100% out-of-pocket, when in the post-ACA world, that will be the case for almost no one."

ACA and Life Care Planners

Some commentators argue: "[I]f defendants in an ACA world are permitted to dispense with the collateral source hearing and present evidence of health insurance coverage directly to the jury, such evidence should significantly curtail the persuasiveness that life care plans’ projections represent actual future medical expenses that are supposedly to be paid completely out-of-pocket by the plaintiff."

Other experts, even those who "believe the ACA changes the underlying reason of excluding collateral source compensation from inclusion in tort cases," anticipate life care planners will play an increasingly important role in personal injury damage analysis.

o Prior to the ACA, life care planners were tasked with identifying medical and living expenses not otherwise required "but for" the accident.

o Under the ACA, these experts maintain life care planners must also identify which health care and living expenses will, and will not, be covered by the ACA's minimum insurance requirements.

o And, despite certain minimum federal standards, these requirements may differ by state.

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Is the ACA Working? (Excerpts from First Year Review by Margot Sanger-Katz – see article citation below.)

“Has the percentage of uninsured people been reduced? o The number of uninsured Americans has fallen by about 25 percent during

the first year, or about eight million to 11 million people. o At least as many people have enrolled in Medicaid…… as have signed up

for private insurance through the new online marketplaces. o Whether the uninsured population is further reduced significantly will

depend in part on whether more states opt to expand Medicaid. Has insurance under the law been affordable?

o 7.3 million people signed up for private insurance through online exchanges during the first enrollment period. 85 percent qualified for federal subsidies that decreased the cost of their premiums.

o First year rate filings by insurers in 21 states suggest that rates will vary widely, but the median premium increases for 2015 for silver plans will be around 4 percent and there will be more insurers in the market.

Has the ACA improved health outcomes? o Most experts say there is not enough data yet on the entire population to

determine whether the law is improving the nation’s health. Will the functionality of the exchanges improve?

o Federal and state officials say that the online health care marketplaces that performed so badly last fall have been upgraded to ensure smoother service when they reopen Nov. 15.

Has the ACA helped or hurt the health care industry? o Wall Street analysts and health care experts say the law helped the

industry financially by providing new customers to insurers and new paying patients to hospitals.

How well has the expansion of Medicaid worked? o The Affordable Care Act allows states to expand Medicaid to people not

previously eligible, including some people above the poverty level – but the United States Supreme Court in 2012 ruled that expansion was optional for states.

o As a result, only [31] states and the District of Columbia have expanded, while Republican opposition in other states has blocked expansion.

Has the ACA contributed to the slowdown in healthcare spending?

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o Health care spending had begun slowing even before the Affordable Care Act was signed into law.

o In the short term, the law could actually drive up health care spending by bringing more insured people into the system.”

Practice Implications for Professionals – Lawyers, MSA Specialists, Life Care Planners, Case Managers

Collateral benefits testimony is being allowed in some courts – potential for mis-information due to “experts” lack of understanding of authorization guidelines, policy limits, vendor and formulary restrictions, and true out of pocket expenses for the plaintiff for best solution medical care.

Majority of cases are mediated – collateral benefits have become a significant topic during mediation discussion.

Risk to practice – potential malpractice for NOT obtaining a quality third party benefits analysis

Time is of the essence – analysis should be initiated PRIOR to case resolution IF client is not clearly eligible for Social Security Disability Income based on

Federal Disability Guidelines – there may be alternative settlement strategies relative to the MSP.

98

For Discussion - Case Example

Client Status Assumptions

Age 48 Years Old

Incident MVA – 18 months ago

Injury Spinal Cord Injury - Incomplete L5-6 Client is currently wheelchair dependent.

Current Benefits Receiving Long Term Disability until retirement age. COBRA health insurance is about to run out.

SSDI Client has NOT applied, Client intends to return to work in a sedentary capacity if possible. Date unknown for attempted return to work.

SSI, Medicaid Not Eligible

Net Settlement $2.5 Million (anticipated)

Sample Analytical Questions: 1. What are the critical considerations in analyzing this case specific to third party

benefits post settlement?

2. Is a MSA required based on current law/rules? (defense says yes, plaintiff attorney says no)

3. Is there a creative strategy for maximizing this client’s ongoing access to best quality health insurance benefits – either through ACA, Medicare, etc?

4. Should a Client ever consider replacing their Medicaid and/or Medicare coverage in favor of a private pay ACA policy?

99

External Resources

"Report on the Patient Protection and Affordable Care Act: Its Impact on the Special Needs and Elder Law Practice", by Scott Solkoff, Spring 2015 NAELA Journal

"Medicare’s Future: Letting the Affordable Care Act Work, While Learning From the Past", by Alfred J. Chiplin Jr. and Bethany J. Lilly, Spring 2013 NAELA Journal

"Anticipating the ACA's Aftershocks: The Nexus Between the Patient Protection and Affordable Care Act and the Medicare Secondary Payer Act", by Jessica Smythe, Claims Management, November 21, 2014.

"How the Affordable Care Act Impacts Nurse Life Care Planners", by Patrick Hindert, Winter 2014 Issue AANLCP Journal.

“Is the Affordable Care Act Working?”, by Margot Sanger-Katz, New York Times, October 26, 2014.

Handouts & Links Presenter Biographies Presentation Power Point Expanded Presentation Outline ACA-related S2KM blog posts

o Affordable Care Act - 1 - reviewing Joshua Congdon-Hohman and Victor A. Matheson's article about the ACA's impact on future medical damages in personal injury cases. (Link: http://s2kmblog.typepad.com/rethinking_structured_set/2013/04/affordable-care-act-1.html )

o Affordable Care Act - 2 - reviewing separate law review articles by Rebecca Levenson & Ann Levin about the ACA's impact on the collateral source rule. (Link: http://s2kmblog.typepad.com/rethinking_structured_set/2013/04/affordable-care-act-2.html )

o Affordable Care Act - 3 - reviewing a Medicare article by Alfred J. Chiplin Jr. and Bethany J. Lilly detailing various cost-saving components of the ACA. (Link: http://s2kmblog.typepad.com/rethinking_structured_set/2013/05/affordable-care-act-3.html )

100

o ACA and Future Medical Expenses - 1 - summarizing a Trial Magazine article by Seth Cardeli. (Link: http://s2kmblog.typepad.com/rethinking_structured_set/2014/06/aca-and-future-medical-expenses-1.html )

o ACA and Future Medical Expenses - 2 - summarizing speakers from prior professional conferences. (Link: http://s2kmblog.typepad.com/rethinking_structured_set/2014/06/aca-and-future-medical-expenses-2.html )

o ACA and Future Medical Expenses - 3 - summarizing authors of papers and articles. (Link: http://s2kmblog.typepad.com/rethinking_structured_set/2014/07/aca-and-future-medical-expenses-3.html )

o NAELA Journal - Recent ACA Articles - summarizing Spring 2015 articles by Scott Solkoff and E. Spencer Ghazey-Bates. (Link: http://s2kmblog.typepad.com/rethinking_structured_set/2015/07/naela-journal-recent-aca-articles.html )

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Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

“How the ACA Impacts Medicare,Medicare Compliance and MSAs”

Patrick J. Hindert, J.D.Managing Director

S2KM LimitedPatrick@s2km.com // (513) 899-2100

Ann Koerner, RN, BSN, CRRNPresident

National Care Advisorsannkoerner@nationalcareadvisors.com

(614) 325-4269

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

102

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Introduction

• Background • Roles of Presenters• Presentation Scope • Presentation Objectives

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Commentators’ Views – Scott Solkoff

• "The ACA is a big new law that includes a mass of new statutes, state and federal regulations, court decisions, and variances that differ from state to state and county to county. Trained professionals, as well as consumers, will be challenged to understand and navigate this new system."

103

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Commentators’ Views –Alfred Chiplin, Jr. and Bethany Lilly

• "The ACA is a vast experiment in paying for high-quality health care while preserving the Medicare program and expanding access to health care for other population segments.Implementation will be a tough, but doable challenge so long as we 'let the tools of the ACA work'."

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Commentators’ Views – Jessica Smyth

• "How does the ACA change the guidelines for Medicare Set-Aside (MSA) preparation and the regulations for conditional payment reimbursement and Section 111 reporting? The short answer to this question is: not at all. "

• "The conclusion that CMS may heighten MSP enforcement as a result of the ACA remains to be seen. The situation as it exists now can be compared to an earthquake; the claims industry is anticipating the aftershock."

104

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

ACA Overview

• Two laws enacted March 2010

• 906 pages of legislation

• 1764 pages of IRS regulations

• Over 24,000 pages of federal regulations

• 2 landmark Supreme Court cases

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

“New Definition” of Health Insurance

• "Old definition" of health insurance policies:– Annual and lifetime limits,– No “medical loss ratio” to control administrative expenses

and profits– Limited or no coverage for people with disabilities or pre-

existing conditions– Restrictions for children under parental policies – Limited preventive care coverage, and– Additional restrictions based on doctor choice or

emergency room access.• “New definition” - ACA health insurance policies now

must include all these features.

105

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

ACA and Medicare

• ACA does not replace or terminate Medicare coverage.• Medicare remains a single-payer system run by the

federal government.• Medicare meets ACA's health insurance coverage

requirements.• Selling a marketplace plan to a Medicare recipient is

illegal.• ACA does have coverage requirements that do affect

Medicare.• Health insurance exchanges do not affect Medicare

coverage or choices.

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

ACA-related Benefits for Medicare Recipients

• Coverage for annual wellness visits.

• Elimination of cost-sharing for most preventative services.

• Increased consumer protections to Medicare Advantage (or Medicare Part C) benefit plans.

• Increased coverage for prescription medications & preventive care.

• Expanded coverage for preventive services without a deductible or Part B coinsurance.

• Rewards for health care providers for enhancing services.

• Discounts and additional coverage to make Part D Medicare prescription drug coverage more affordable.

• Gradually closing of the “donut hole”.

• Extends the Medicare trust fund to at least 2029.

106

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Additional ACA Cost-containment Programs

• Patient-Centered Medical Home –not likely to be fully funded

• Medicare Shared Savings Program –moving forward

• The Independent Payment Advisory Board

• Quality Review Mechanisms –restrict payments for services & procedures that do not meet care standards

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

ACA and Medicare Compliance

• ACA does not explicitly address:– MSAs – conditional payment reimbursement – or Section 111 reporting

• ACA and MSP Act share a common objective -preserve fiscal integrity of Medicare Trust Fund

• ACA extends Medicare trust fund to at least 2029• ACA includes cost-containment programs to reduce

future Medicare costs

107

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Future Impact of ACA on MSP Enforcement?

• Question: Will the ACA increase enforcement of §111 reporting & conditional payment reimbursement?

• ACA has competing purposes.• ACA has many provisions designed to identify & prevent fraud.• ACA provides the DOJ and the OIG with greater access to

CMS databases.• ACA expands Medicare’s Fee-for-Service RAC program to:

– Medicaid– Medicare Advantage (Part C)– and Medicare drug benefit (Part D) programs.

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Does the ACA Eliminate the Need for MSAs?

• Argument: Use ACA to fund future medicals.

• Counter Argument: Illegal to sell marketplace plans to Medicare beneficiaries.

• Conclusion: The ACA neither addresses nor changes MSA guidelines.

108

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Collateral Source Rule

• Definition and Impact• Background: Common law and Restatement (Second) of

Torts • Tort Reform: Modified in 39 states.• Subrogation: Negates collateral source rule.

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

ACA and the Collateral Source Rule

• Subject of debate and litigation.

• Will impact MSA work product.

• Prior to ACA - the "pre-existing condition" exclusion

• Key issue: “…whether it remains fair to continue to force the fiction upon the jury that future medical expenses projected by a plaintiff’s life care plan will be paid 100% out-of-pocket, when in the post-ACA world, that will be the case for almost no one."

109

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

ACA and Life Care Planners

• Some experts argue: ACA negates persuasiveness of life care plans’ projections.

• Other experts anticipate increasing role for LCPs in personal injury damage analysis. – Prior to ACA, LCPs identified expenses not

otherwise required "but for" the accident.

– Under ACA, LCPs must also identify which expenses will (will not) be covered by ACA's minimum insurance requirements – may differ by state.

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Is the ACA Working?

• Reduced percentage of uninsured people?

• Insurance more affordable?

• Improved health outcomes?

• Improved exchange functionality?

• Helped or hurt the health care industry?

• Has Medicaid expansion worked?

• Has ACA reduced healthcare spending?

110

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Practice Implications for Professionals-Lawyers, MSA Specialists, Life Care

Planners, Case Managers - (part 1 of 3)

• Collateral benefits testimony is being allowed in some courts –– potential for misinformation due to “experts” lack

of understanding of authorization guidelines, – policy limits– vendor and formulary restrictions, – and true out of pocket expenses for the plaintiff for

best solution medical care.

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Practice Implications for Professionals-Lawyers, MSA Specialists, Life Care

Planners, Case Managers - (part 2 of 3)

• Majority of cases are mediated –collateral benefits have become a significant topic during mediation discussion

• Risk to practice –potential malpractice for NOT obtaining a quality third party benefits analysis

111

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Practice Implications for Professionals-Lawyers, MSA Specialists, Life Care

Planners, Case Managers - (part 3 of 3)

• Time is of the essence –analysis should be initiated PRIOR to case resolution

• IF client is not clearly eligible for Social Security Disability Income based on Federal Disability Guidelines – there may be alternative settlement strategies relative to the MSP.

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

For Discussion – Case Example

Client Status Assumptions

Age 48 Years Old

Incident MVA – 18 months ago

Injury Spinal Cord Injury  ‐ Incomplete L5‐6Client is currently wheelchair dependent.

Current Benefits Receiving Long Term Disability until retirement age.COBRA health insurance is about to run out.

SSDI Client has NOT applied,Client intends to return to work in a sedentary capacity ifpossible.   Date unknown for attempted return to work.

SSI, Medicaid Not Eligible

Net Settlement $2.5 Million (anticipated)

112

Annual ConferenceSeptember 30, 2015

How the ACA Impacts Medicare, Medicare Compliance and MSAs

Patrick J. Hindert, JD &Ann Koerner, RN, BSN, CRRN

Handouts & Resources

• Presenter Biographies

• Presentation Power Point

• Expanded Presentation Outline

• Recommended Articles

• ACA-related S2KM blog post links

113

11th Annual Meeting & Educational Conference

Thursday, October 1, 2015 9:00 am - 10:00 am

Long-Term Narcotic Use in MSAsPanelists

Steve Miller, SJM EnterprisesMeredith Warner, Warner Orthopedics snd Wellness

Prescription drugs are known to escalate the cost of an MSA exponentially. While the short term use of narcotics to treat certain

conditions has proven to result in beneficial outcomes, long term use of these medications can have lethal results. Our panelists will discuss

the long-term effects of narcotics on the body, and present evidence indicating why their long-term use in an MSA should be minimized.

-

Panelists

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Medical Evidence

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self-promotion. Self-promotion will prohibit the speaker from any future presentations.

115

Homer, Iliad• Pema, algos, adyne Suffering of the soldiers on

the battlefield Now pain, analgesia and

dolour

• Opium seen in evidence from Mesopotamia; 3000BC In Coffins in Egypt 1500BC With Alexander the Great

300BC With the spread of Islam

into China

Laudanum was popular with women of the victorian era

Dioscorides; physician of Roman army• Explained:• The seeds of the poppy could be used against

sleeplessness and as a pain reliever, but warns that“in greater doses it will make men lethargic and may kill the patient”

John Jones of Oxford re: Laudanum• “can cause intolerable anxiety, and depression and a

miserable death”

116

Until 1903 cocaine was in coca colaAlcoholism treated with morphine substitutionEnd of 19th century 10% of population and

MDs dependent on morphineOsler stated in 1892 that morphine was

‘God’s own medicine’ but also that those dependent on opium were “inveterate liars and no reliance whatever can be placed on their statements”• Also, the opium habit is ’difficult to treat’

Could buy a syringe and cocaine for $1.50 from Sears catalogue in 1890

117

Reports of large numbers of street addicts, of whom many began as medical patients on prescription drugs• Early 1900s and now

Opium addicts: mostly women (66-75%) (prescribed legal opiates for ‘female problems’), white men and Chinese in opium dens (legal then)

1908 Poisons and Pharmacy Act (GB)1914 Harrison Act (USA)

• Taxing import and production of opium and coca• Politically incorrect reasoning

249 U.S.96,99 (1919)Physicians could not prescribe narcotics

solely for maintenance• Many arrested and jailed• MDs stopped prescribing to addicts

Linder v United States (1925)• Federal government has no power to regulate

medical practice• Since superseded

Now we can prescribe with no limits at all

118

Just because you have pain does not mean you can’t be or become an addict• 3-23% of chronic pain patients have dependence• Lifetime prevalence of addiction is 23-54% of chronic

pain patients• Lifetime prevalence of addiction in general population

is 16%

• The argument that having pain prevents addiction is wrong Higher rate with pain patients: 23-54% > 16%

Sedation Loss of energy Weakness Weight gain Sweating Sexual dysfunction Constipation Nausea/pruritis Allodynia and

Hyperalgesia Multiorgan failure Demotivation/lethargy

Most common reason to be on methadone/narcotics today?• Lower back pain

119

3 months of methadone Rx for chronic pain• 75% at 81.5mg = ‘good’ pain relief• 25% at 187.5mg – ‘moderate’ pain relief• Global quality of life rating – 50.8 73 in general population 33 in Swedish chronic pain patients

• 5 of 60 could return to work• 68% had psychiatric disorders• 40-60% with side effects

Hypothalamic-Pituitary Axis disorders• Thyroid, adrenal and

gonads, integral to organ function as well

Opioids effect this Repeated ESIs effect

this

Thyroid dysfunction symptoms:• Weakness• Apathy• Edema• Constipation• Anovulation• Headache, joint pain

and muscle cramps

120

DHEA deficiency:• Decreased libido• Fatigue• Depression

Hypogonadism

Adrenal deficiency• Altered blood glucose• Changes in immune

system• Decreased anti-

inflammation• Weakness, fatigue,

anorexia, nausea, hyponatremia

40 chronic pain patients with strong opioids v 20 chronic pain patients without opioids for a year• Measured hormonal production• Measured pain

Opioid group had sexual disturbance and menstrual irregularities, low LH and FSH, low prolactin, suppressed cortisol response

Similar pain control recorded

121

Between 26.4 and 36 million people abuse opioids worldwide• 2.1m in USA with prescription drug abuse; 2012• 467,000 Heroin addicts

Quadrupled # deaths since 1999 from drugsThere is a relationship between prescriptions

and heroin abuse• As # prescriptions have risen, so have # heroin users• Recent clamping down on prescriptions has increased

# heroin Increases in Hepatitis C now……Solvadi is not cheap

1991 – retail prescriptions = 76million2013 – retail prescriptions = 207 million

Louisiana = highest number of narcotics prescriptions in WC

122

Tamper proof medications and long-acting narcotics are ‘only for pain’ and ‘appropriate for chronic pain patients’: These deter abuse

Actually, once tampered with they give a better high

Not true:• All long-acting meds are

tampered with• Opana Er Grind, cut and chew 2006 market, most widely

abused

• Fentanyl patch Brew tea chew

• Sustained Oxy

• Just google this…..

So I got the new Opana 40's this month and at first I was …. bummed. I have been snorting Opana for over 2 years for my back pain and I was so worried about the new ones coming out. I was worried they wouldn't work as well and after snorting them for that long oral use might be deemed pointless.

Well, where there's a will there's a way. They are crush resistant, not grind proof. So I grind em up and mix in a little B12 to stop the gelling.... and snort like normal. Without the B12 its like super gel..... These things gel up worse than OP's... this method works amazing for OP's as well.

Anyways I got the most ridiculous nod off of em and am shocked to say I like embetter... The only downside is.. You gotta work for your high and grinding one on a pedda egg takes 10 minutes and will wreak havoc on your hands... I am looking into a dremel tool or something of the like to make grinding easier. It only took one day to figure out crisping is stupid... Also adding roxi instead of B12 helps but not as much... there is something about the consistency of B12 works really well,

So do any of you grind your new Opana if so what tools do you use? I am considering a dremel tool, I also heard the dog nail trimming tool. I hear it works but I am questioning the sand paper... with a tool like a dremel I could do what takes 10 minutes in 30 seconds. Any ideas would be greatly appreciated. Also I hope this helped someone who has had these same issues with these pills

123

Are we being hurt more often?• Cars and worksites are safer• Number MVA 1990 = 11.5m, 2009 = 10.8m• Number MVA deaths 1990 = 46.9k, 2009 = 35.9k

NO, we just take more pills for no apparent reason:• Prior NMPR use accounts for 80% of heroin initiates• CDC may recommend dosage >90MED to be avoided

I blame us….the doctors….and the politicians….and the media…..and the attorneys

629% increase in ESI spend423% increase in opioid spend for back pain307% increase in MRI220% increase in fusion rates

No change in population level outcome improvement or disability rates (higher now)

No change in number of office visits for back pain since 1990

124

33-66% of imaging is inappropriateNormal findings are used to rationalize

treatment• Surgery rates are highest where imaging rates are

highest (eg: Louisiana)• Studies show no advantage to early and more

imaging; no change in pain, function, quality of life or improvement

More than 50% of opioid prescriptions are for back pain• Population based studies: many patients receiving

opioids for NCP have higher pain and poor life quality• No evidence to support use for chronic pain• Questionable benefit• Many side effects, including hyperalgesia

Hospital and clinic ‘ratings’ are heavily dependent on patient ‘satisfaction’ and ‘pain control’

125

McAllen TX example: 7$K more per person per year than the average city

No better careMost McAllen hospitals performed worse

than El Paso’s (example city)Spend grew from1992 ($4891) to 2006

($15,000); average income in McAllen 2006 = $13,000

Dartmouth Medicare data, D2Hawkeye and Ingenix data• Compared to national patients, McAllen TX

patients received more tests, treatment, medication, home care and surgery

The more Medicare spend per patient, the lower the care ranking• Lowest care states with highest spend? TX, CA,

FL, LA• MN (Mayo clinic) spends $6688 per patient v 14k

for McAllen

126

McAllen and others like it versus:• Kaiser Permanente• Intermountain Healthcare• Geisinger• Mayo Clinic

More pills, more surgery and more $$ does not result in better care

It is likely that we do not need a tremendous amount of narcotics to adequately treat pain….

108 million ED visits in 2005; 1.4m drug visits• 31% illicit only• 27% pharmaceutical only• 36% combo

127

Patients know far less about the decision they are making than the prescriber• Opioids have limited to no success• Opioids have many side effects• Opioids have hyperalgesia and lose effectiveness over

timeBuyers have a disadvantage when they know

less about a good than the seller• Car mechanics and surgeons Kenneth Arrow, Nobel Prize in Economics

• Federal Government and Pharmaceutical companies

350million persons• 15million nuclear med scans• 100million CT and MRI scans• 10billion lab tests

Over-diagnosis• Finding things that don’t matter and then treating

them• More money spent on spinal fusion than any other

operation ($13B in 2011)

128

Wal-mart uses ‘Centers of Excellence’ for certain surgery• One 30-yo-male had fusion surgery recommended

based on the finding of a degenerative disc on MRI• Decided to participate in the COE program: Went to

Virginia Mason in Washington to have the surgery his local physician recommended

• They found no evidence that the disc was a problem and did not think surgery was needed

• 30% of indicated surgeries are unnecessary according to COE data

Between 1997 and 2005 National spending on back-pain increased 66%

Between 1997 and 2005 there has been no improvement in complaints of back pain

The 30-yo-male was treated with gabapentin, exercise and time; 6 weeks later had no pain and did not have the fusion; also had no narcotics

129

Reduced hepatic and renal function• Best practice says use lower doses, less frequently

Opioids are immunosuppresantsOpioids with benzos = respiratory depressionOpioids cause constipationOpioids increase risk of driving poorlyThe elderly have increased fat, decreased

muscle and decreased body water• This effects drug metabolism and distribution• Decreased function of P-450 pathway also

Prior discussion of endocrine problems and quality of life reports

Blood concentration of morphine:• Average concentration to achieve therapeutic

analgesia: 0.065mg/L• Surgical anesthesia: 2mg/L• Following oral doses of 10-80mg: .05-.26mg/L• Following IV dose of 8.75g/KG heroin: 0.44mg/L• Following IV overdose heroin: 0.70mg/L

Data from urine tox screen• 36% positive inconsistent, 13-18% negative

inconsistent• Blood studies found concentrations in functional pain

patients well above therapeutic; often at toxic levels

130

100% global use of hydrocodone81% global use of oxycodone66% increase in number of heroin users

from 2002 to 2012• Growth among women, higher incomes and

private insured too• Strongest risk factor for heroin addiction? Being a rock star? No, abusing prescriptions

LBP is clustered into distinct provider characteristic groupings• Compared on demo, health behavior, chronic and

symptomatic disease burden, physician efficiencySurgery and 3++ opioid group was only

10.4% of cohort:• More MRI, ER, Inpatient and injectables• Surgery patients were older, had more FM and had

PCPs with bad efficiency scoresOver-diagnosis = overtreatment (long-term

opioid usage)

131

5% of LBP patients were moderate to heavy users of pain pills

Associated with higher proportion of depression, comorbidities, anxiety, current smokers, sleep disorders, somatoform

Peaks at 45-64 (should go down after that)Narcotic prescriptions have increased b/w

2002 and today for this conditionPhysician visits with a complaint of back pain

have increased from 44.6m in 2004 to 52.3m in 2012• Prevalence of LBP has remained stable since 2005

There are less work injuries, car accidents overall• Narcotics must be causing more pain

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Opioids are good for short-term pain (2 weeks) No clear evidence that they are good for chronic

pain Use of prescriptions for chronic pain are mirrored

by an increase in abuse nationally There has been no change in outcomes

• 1990s doctors did not use narcotics often for non-CA pain• Now we do; there has been no change in pain• Number of disability applicants in 2000 = 1,330,558; in

2009 = 2,816,244; in 2014 2,521,459 We are in more pain now and more disabled despite more

narcotics

More people in pain despite all technologySafer cars and work sites but more painMore obesity and deconditioningDifficult economic environmentSSDI that is easier to getMore litigationMore opioids than ever, more deaths and

addiction, more heroin usage and alsoMore Hepatitis C

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Rates of disability increase in times of unemployment• This means disability

must have nothing to do with medical issues, but rather economic ones

• As work is known to betherapeutic, keeping peoplefrom working makes no sense

We pay people $200 B per year NOT to work

Only 13% of the male growth in SSDI was due to age; only 4% of the female growth was age related• Most of the growth was due to Reagan and that

Congress relaxing what qualified as ‘disability’ to include things like back ‘pain’ Placed greater weight on the applicants own assessment of

their disability; to include their self-reports of pain and discomfort

Patient’s own doctor mattered more than government assessment Binder & Binder, West Virginia scandal, NYC RR workers

• Economic value of disability payments also accounts for growth

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Americans actually have fewer disabling conditions than they did 40 years ago

SSDI has exploded for MSK pain and for mental health

SSDI for CA, stroke, MI, heart disease, amputation, etc have stayed the same

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Found doctors on Craiglist• At peak had 12 MDs

MD paid flat fee per opioid prescription written• $75-$100 per script• 100 pts per day

MD earned $1.95M per year

In 2 years of business• 20M pills• $40M revenue

Walk-in patients• $200 initial• $150 FU• Sold the pills too• 180 30mg for $2/pill• Bought pills for 70c

National number of prescriptions in 2011 = 335 millionPopulation = 350million

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Market for heroin = $55 billion world• With opiates = $65 billion• 1 million trafficker jobs • Allows Afghanistan (Taliban) to have an economy 90% world heroin production

Painkillers in 2011 = $9B USA• Number of pain clinics has exploded 800 in FL in 2011; now 508 since Operation Oxy Alley

• DEA allowed 98million grams of oxycodone in 2012; up 40% from 2008

“people…can say they are in pain, you can’t prove otherwise. There’s no way to keep them from getting their medication.” - Jeffrey George

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Long‐Term Narcotic Use in MSAs 

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

Why is it a problema. Increasing number of patients using opioids on a “long‐term basis” (1)b. Three out of four injured workers receive opioid prescriptions for pain relief following workplace injuries 

Long‐Term Narcotic Use in MSAs 

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

Why is it a problemc. Increasing costs – both new products and currently existing products – resulting in an average 7.3% c;ost per prescription in 2014. (2)d. One positive note..decreasingutilization..5.4% in 2014. (3)

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2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

Medications used to treat side effects result in VERY high costs Erectile DysfunctionLaxativesAntipsychoticsAntidepressantsAdditional pain medications Stimulants Other 

Long‐Term Narcotic Use in MSAs 

Problem? What problem??

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

• narcotic utilization decreased 7.4%• average morphine equivalent dose per script decreased 4.5%, The percent of injured workers utilizing opioid analgesics decreased from 61.8% to 60.2%, (1)

Long‐Term Narcotic Use in MSAs 

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Problem? What problem?? (cont.)

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

• Generic utilization increased 5.9% and is attributed in part to the generic releases of two top 10 medications, celecoxib and esomeprazole (4)

Long‐Term Narcotic Use in MSAs 

Selected trends in prescription costs ‐ 2014

• 7.3% average prescription cost per claim.   (4)

• Double‐digit Average Wholesale Costs (AWP) increases  

• NSAID class increased 21.9% in cost per script

• hydrocodone‐acetaminophen products had a 10.2% increase in AWP billed per prescription

Long‐Term Narcotic Use in MSAs

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Long‐Term Narcotic Use in MSAs 

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Utilization Review becoming a BIG thing!

Retrospective

Concurrent

Prospective

Long‐Term Narcotic Use in MSAs

• Retrospective –• detects patterns in prescribing, dispensing, or administering drugs to prevent recurrence of inappropriate use or abuse (6)

• Triggers that range from inappropriate drug and medical treatment to a worker's comorbid conditions and negative mindset signal that a claim can result in high costs and warrants intervention, whether through a nurse case manager, drug utilization review or other method. (5)

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Long‐Term Narcotic Use in MSAs

• Concurrent –• ongoing monitoring of drug therapy during the course of treatment (6)

• Case management or health management

• POS (Point of Sale) programs at the pharmacy dispensing area

• alert prescribers to potential problems DURING therapy• drug‐drug interactions

• duplicate therapy (poly‐pharmacy)

• over or underutilization (refills)

5. http://www.businessinsurance.com/article/20150906/NEWS08/3091399946. https://www.prxn.com/docs/PRxN%20DUR.pdf

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

Long‐Term Narcotic Use in MSAs

• Prospective –• evaluation of a patient's therapy before medication is dispensed (6)

• Infancy

• POS (Point of Sale) with EHRs

• STOP ineffective, dangerous, fraudulent therapies• drug‐drug interactions

• duplicate therapy (poly‐pharmacy)

• over or underutilization (refills)

5. http://www.businessinsurance.com/article/20150906/NEWS08/3091399946. https://www.prxn.com/docs/PRxN%20DUR.pdf

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Long‐Term Narcotic Use in MSAs 

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

Treating adverse effects is a MAJOR issue and long term!a.Respiratory Depressionb.Mental status changesc. Opioid‐induced endocrinopathyd.Unmanageable sleep‐disordered breathinge.Opioid‐induced hyperalgesiaf. Opioid‐induced tolerance

Long‐Term Narcotic Use in MSAs

• More opioids enter the market• Hysingla ER ‐ hydrocodone

• Opana – oxymorphone

• Zohydro ER ‐ hydrocodone

• Xtampza ER (E‐R oxycodone) recommended for approval (7)

• Avridi (I‐R oxycodone) recommended for denial (8)

• STOP ineffective, dangerous, fraudulent therapies• drug‐drug interactions

• duplicate therapy (poly‐pharmacy)

• over or underutilization (refills)

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Long‐Term Narcotic Use in MSAs

• Variability across the country• 16% of injured workers in Louisiana receive opioids long term

• 10% in states such as New York, Pennsylvania, and Texas.• <4% in Wisconsin or Indiana

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

Long‐Term Narcotic Use in MSAs 

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

AMERICAN ACADEMY OF NEUROLOGY GUIDELINESOpioid benefits for noncancer conditions (8)– very helpful vs. headache, migraine, fibromyalgia, 

chronic low‐back pain.Opioid risks noncancer conditions‐ overdose, addiction, deathOpioid long‐term risks – poorer outcomes (9), longer 

disability (10,11), higher medical costs among injured workers (12,13)

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Long‐Term Narcotic Use in MSAs 

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

Opiod overdosage facts:40% seeing multiple physicians40% received >100 MEDs /day20% saw one physician and  received 

<100 MED/day. (14, 15, 16, 17, 18)

Long‐Term Narcotic Use in MSAs 

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

What could happen if?????a. More opioids enter the marketb. Price escalation continuesc. Decision‐makersd. Guidelinese. Effective change implemented

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Long‐Term Narcotic Use in MSAs 

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

QUESTIONS?

Long‐Term Narcotic Use in MSAs 

2015 NAMSAP ANNUAL MEETING NEW ORLEANS, LA.

References (all web sites accessed September, 2015):1.  http://www.lexisnexis.com/legalnewsroom/workers‐compensation/b/recent‐cases‐news‐trends‐developments/archive/2014/10/01/wcri‐studies‐show‐75‐percenworkers‐get‐opioids‐but‐don‐t‐get‐opioid‐management‐services.aspx#sthash.V1Al2bYJ.dpuf2.  http://coventrywcs.com/web/groups/public/@cvty_workerscomp_coventrywcs/documents/webcontent/c142815.pdf3.  http://lab.express‐scripts.com/insights/workers‐compensation/workers‐compensation‐rx‐spend‐increased‐1‐9‐in‐20144.  http://coventrywcs.com/web/groups/public/@cvty_workerscomp_coventrywcs/documents/webcontent/c142815.pdf5.  http://www.businessinsurance.com/article/20150906/NEWS08/3091399946.  https://www.prxn.com/docs/PRxN%20DUR.pdf7.  http://www.drugs.com/news.html8.  http://formularyjournal.modernmedicine.com/formulary‐journal/news/fda‐nixes‐one‐painkiller‐recommends‐another9,  http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodManagingSideEffectsFactSheet23May2013v1HiResPrint.pdf10. Franklin GM, Stover BD, Turner JA, Fulton‐Kehoe D, Wickizer TM. Early opioid prescription and subsequent disability among workers with back injuries: the DisabiIdentification Study Cohort. Spine. 2008;33(2):199‐204.11. Swedlow A, Gardner L, Ireland J, Genovese E. Pain management and the use of opioids in the treatment of back conditions in the California Workers’ CompensatioOakland, CA: California Workers’ Compensation Institute. 2008.12. Wang D, Hashimoto D, Mueller K. Longer‐term use of opioids. Cambridge, MA: Workers Compensation Research Institute. 2012.13. Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsand late opioid use. Spine. 2007;32(19):2127‐32.14. Edlund MJ, Martin BC, Fan MY, Braden JB, Devries A, Sullivan MD. An analysis of heavy utilizers of opioids for chronic noncancer pain in the TROUP Study. J Pain SyManage. 2010;40:279‐89.15. Katz N, Panas L, Kim M, et al., Usefulness of prescription monitoring programs for surveillance – analysis of Schedule II opioid prescription data in Massachusetts, Pharmacoepidemiol Drug Safety. 2010;19:115‐23.16. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose. Ann Intern Med. 2010;152:85‐92.17. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose‐related deaths. JAMA. 2011;305:1315‐21.18. Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300:2613‐20.

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11th Annual Meeting & Educational Conference

Thursday, October 1, 2015 10:30 am - 11:30 am

Legal UpdatePanelists

Annie Davidson, O’Meara, Leer, Wagner & Kohl, P.A.Michele Ready, Walton Lantaff Schroeder & Carson LLP

Heather Schwartz Sanderson, Franco Signor LLC

In what has become a NAMSAP tradition, you are not going to want to miss the annual Legal Update. Court cases across the country continue

to address MSP compliance issues. Our panelists will introduce new cases that have transpired over the year, and offer up their own legal

commentary on the ramifications of these decisions.

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2015 Legal Update

Michele E. Ready, Esq.Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP

Annie M. Davidson, Esq., CMSP

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DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

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Program OverviewProgram Overview

This program seeks to provide and overview of case law developments over the past year and will cover the following areas of substantive case law:

• MSP Private Cause of Action

• Medicare Advantage Plans/Rights of Recovery

• MSP and False Claims Act

• Other Miscellaneous  Cases

4

Program OverviewMSP Private Cause of Action

• Estate of McDonald v. Indemnity Insurance, 46 F. Supp. 3d 712 (W. Dist. Ky. 2014)

• Holmes v. Farm Bureau Gen. Ins. Co., 2015 Mich. App. LEXIS 1031 (Mich. Ct. App. 2015)

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Program OverviewMedicare Advantage Plans/Rights of Recovery

• Prior Cases of Significance

– Care Choice HMO v. Engstrom, 330 F.3d 786 (6th

Cir. 2003)

– Humana v. Reale, 2011 U.S. Dist. LEXIS 8909 (S. Dist. Fla. 2011)

– In re: Avandia,  685 F.3d 353, 362 (3rd Cir. 2012) 

– Parra v. Pacificare of Arizona, 21715 F.3d 1146 (9th

Cir. 2013)

– Collins v. Wellcare Healthcare Plans, 2014 U.S. Dist. LEXIS 17442 (E. Dist. La. 2014)

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Program OverviewMedicare Advantage Plans/Rights of Recovery

• MSP Recovery, LLC v. Progressive Select Ins. Co., 2015 U.S. Dist. LEXIS 47784 (S. Dist. Fla. 2015)

• Humana v. Western Heritage Ins. Co., 2015 U.S. Dist. LEXIS 31875 (S. Dist. Fla. 2015)

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Program OverviewMSP and False Claims Act

• United States of America ex. rel. Dr. Kent Takemoto v. ACE et al., 1:11‐cv‐00613, USDC WD NY

• United States, ex. rel. J. Michael Hayes v. Allstate Insurance Company, et al., 1:12‐cv‐01015, USDC WD NY

8

Program OverviewOther Miscellaneous  Cases

• Treakle v. CSM Medicare Set‐Aside, 2015 U.S. Dist. LEXIS 20619 (Dist. Ct. D.C. 2015)

• Colorado Dept. of Health Care Policy and Fin. v. S.P., 2015 Colo. App. LEXIS 912 (Colo. Ct. App. 2015)

• Tucker v. Cascade Gen., Inc., 2014 U.S. Dist. LEXIS 160265 (Dist. Ore. 2014)

• Stayton v. Delaware Health Corp., 2014 Del. Super. LEXIS 481 (Sup. Ct. Del., Kent 2014)

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Questions & Answers

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Presenter Contact Information

Annie M. DavidsonAttorney at LawO’Meara, Leer, Wagner & Kohl, P.A.Phone: (952) 806‐0478E‐mail: amdavidson@olwklaw.comTwitter: @attyannie

Michele E. ReadyPartner/Attorney at LawWalton Lantaff Schroeder & CarsonPhone: (305) 671‐1344E‐mail: mready@waltonlantaff.com

Heather Schwartz SandersonChief Legal OfficerFranco Signor, LLCPhone: (716) 877‐4677E‐mail: Heather.Sanderson@francosignor.com

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11th Annual Meeting & Educational Conference

Thursday, October 1, 2015 1:00 pm - 2:00 pm

Allocator Track Re-Review / Reconsideration

Panelists Michelle Letter, Consultant

Jeff Knipper, Contact Claims Services IncorporatedJames Raines, Breazeale, Sachse & Wilson, L.L.P

The preparation of an MSA can be a complicated task. Allocators make their best effort to ensure they are providing the most accurate projection of future medical costs they can, but what does one do when an error is made or records were omitted that can affect the final number that was

approved by CMS? Our expert panelists will discuss circumstances surrounding this issue, and a best practices approach to reaching a

resolution.

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Re‐review Panel

Michelle Letter, NovareJeff Knipper, CCSI

James Raines, Breazeale, Sachse & Wilson

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DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

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Objectives:

• Identify the basics of the re‐review process, as defined in the WCMSA Reference Guide

• Discuss the 2014 proposed expansion of the re‐review process by CMS

• Review of  discussion of re‐review at the recent meeting of the Board of Directors of NAMSAP with CMS. 

• Describe specific examples of success and failure with the re‐review process from the allocator's perspective 

• Explain the legal perspective of the re‐review process

Basics of Re‐review

Taken from the WCMSA Reference Guide:

• No formal appeal process

• When will CMS re‐review? 

– Obvious mistakes (ie: math error, failure to recognize medical records)

– Additional evidence (dated prior to original submission) 

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Basics of Re‐review (cont.)

• Submitted through the web portal or via mail

• Considered “in order of receipt”

• If not approved on re‐review and case is settled with lower MSA amount, “CMS will not recognize settlement”

Proposed Re‐review expansion

• In February of 2014, CMS issued a “request for comments” to a proposed expansion of the re‐review process

• Limited to: 

– Cases approved in last 180 days

– Case had not settled 

– No prior re‐review

– Change of amount greater than 10% or $10,000

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Proposed Re‐review expansion (cont.)

• Expanded reasons to consider re‐review:

– Disagreement on medical record interpretation

– Services priced out that are no longer needed or change in treatment plan

– A recommended drug should not be used because of potential harm to beneficiary

– Dispute of inclusion of unrelated body parts

– Dispute of rated age used to calculate life expectancy

Proposed Re‐review expansion (cont.)

• 30 day timeframe for re‐ review

• Re‐reviews handled by experts best skilled to review the issue at hand

• Possible elevation to Regional Offices, where issues involve issues ‐ court findings and policy issues

• Expansion of the re‐review process has not occurred to date.

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NAMSAP Board meets with CMS

• NAMSAP Board Members met with CMS MSP Operations Management Team in June of 2015

• Per CMS, Re‐review expansion had been delayed due to other pressing matters (WCRC backlog and implementation of the SMART act)

NAMSAP Board meets with CMS (cont.)

• CMS’s numbers:

– 4.4% of cases submitted for re‐review

– Of those, 70% of those re‐reviewed were upheld

• Based on these numbers, CMS staff felt Re‐review expansion may not be needed

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NAMSAP Board meets with CMS (cont.)

• NAMSAP indicated Re‐review expansion was needed:

– When treatment plan or pharmacy changes significantly

– For difference in in interpretation of jurisdictional code

• NAMSAP also suggested a one year timeframe (instead of 180 days) following submission for accepting re‐review requests

• CMS stated that they hope to release new re‐review guidelines by the end of 2015

Basic Examples of Re‐review #1

• Medications (Hydrocodone, Tizanidine, Diclofenac) only filled one time under the comp claim and the records indicated "as needed" use, therefore allocated at as‐needed usage. 

• CMS did not agree and allocated them at 12 times yearly, doubling the prescription allocation.

• Re‐review requested and pharmacy listing and medical records re‐sent. 

• CMS agreed with re‐review and approved original MSA.

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Basic Examples of Re‐review #2

• Wrong fee schedule used by CMS to price medical items and services

• CMS often uses state fee schedule to price treatment on longshore claims. Longshore claim medical reimbursement is dictated by  OWCP fee schedule 

• Not always in best interest of WC payer to have CMS correct this error but CMS will comply if requested

Basic Examples of Re‐review #3

• Re‐review request based on expired rated ages used by CMS to determine median rated age. My exclusion of the expired rated ages resulted in higher median rated age and therefore lower MSA

• CMS denied request by citing an operating rule not publicly available that allows them to add 2 years to each rated age making the expired RA and their lower median RA valid

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Basic Examples of Re‐review #4

• Re‐review request based on supplemental medical from treating physician clarifying prior opinion on prescription medication

• Response from CMS pending at time of slide development

Complicated Examples of Re‐review #1

• Two separate claims – WC (right lower extremity CRPS) and Malpractice (Meningitis and sequelae) ‐MSA was for WC settlement only 

• Malpractice case decided by a jury in favor of the claimant, and order for ongoing treatment of meningitis and its sequelae (seizures, depression) were to be paid under separate funding. 

• Judgment and depositions sent with submission.

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Complicated Examples of Re‐review #1 (cont.)

• Cymbalta was added back into the Workers' Compensation MSA, even though records and supportive docs indicated it was used for treatment of depression, which was a result of the malpractice‐related meningitis

• Letters obtained from treating physicians stating Cymbalta was for treatment of depression and not lower extremity symptoms. Judgment and depositions re‐sent with re‐review request

• CMS upheld original counter higher

Complicated Examples of Re‐review #2

• Claimant sustained a traumatic amputation below the elbow. 

• Arm prosthesis replacements allocated over life expectancy, but the myoelectric hand was included on the Non‐Medicare portion of the report. Medicare policy, the manufacturer, and the prosthetist all stated that the prosthetic hand portion of the prosthesis would NOT Medicare‐covered.

• Myoelectric prosthetic hand replacements ($77,000 each) added back into over the life expectancy

162

Complicated Examples of Re‐review #2 (cont.)

• Medicare partially agreed with the Re‐review – they agreed that the myoelectric hand was not Medicare‐covered, but they substituted a hand that was Medicare covered (even though the claimant has not been prescribed that hand) instead of leaving the currently prescribed hand under non‐Medicare. 

QUESTIONS?

163

11th Annual Meeting & Educational Conference

Thursday, October 1, 2015 2:00 pm - 2:30 pm

Allocator Track Data & Development Committee Update

Panelists Debbe Marcinko, Marcinko Consulting LLCSandra Mackler, Mackler Associates, LLC

NAMSAP’s Data & Development Committee (DDC) was created several years ago with the goal of compiling data and identifying trends

surrounding the projection of future medical costs within an MSA, and the subsequent approval and/or counter from CMS. Our panelists from DDC will present the most updated information they have compiled over the

last 18 months to help identify trends that will help lead to a more efficient and cost effective MSA.

164

Data & Development Committee October 1, 2015

Sandra Mackler, M.Ed., CRC, CDMS, MSCC

Debbe Marcinko, RN,BSN,MA, CRN, CMC, CRC, CLCP, CNLP, MSCC

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

165

Mission

• Identifying and tracking of current trends and common issues within the MSA vendor community.

• Advising our Board of Directors, of issues which are universal with the vendor community and seek their assistance in communicating these issues with CMS.

2014-2015 Issues

• Development Letters• Requesting of information that is not

related to the work injury/injury date being settled

• Inclusion or exclusion of procedures

166

Medications

• Variance in cost of medication ( vendor as well as wcrc issue)

• Inclusion or exclusion of medication by the wcrc

Procedures

• Arthroscopy-Knee ( $3,972.83-$4,21.02)Shoulder ( $5,102.00)• Arthroplasty-Knee ($25,849.28-$69,542.60)Shoulder ($25,119.19-$25,410.56)• EMG/NCS-$492.06-$725.58

167

Procedures

• ESI-Cervical ($1,089.56-$1,725.00)Thoracic ($1,215.99)Lumbar ( $1089.56-$1,691.07)• FusionCervical ($23,217.20-$37,778.36)Lumbar ($44,262.58-$49,868.89)

Procedures

• MRICervical ($885.71-$1,988.45)Thoracic ($886.58-$4,753.20)Lumbar ($547.60-$882.24)• PT-Frequency ( breakdown by body part or global number of treatments)-DDC is currently tracking for frequency with diagnosis and if the PT is global or per body part- breakdown per body part, most frequently seen at this time

168

Procedures

• Replacement frequency:SCS- q. 7-9 yearsTKR- 1 x q. 15 years• X-ray,Frequency generally every 4-6 years, depending on the body part

Variance in Regional Office Requirements

• Response time –Currently 8-10 days• Documentation RequirementInformation needed when requesting a funding change from lump sum to annuity

169

11th Annual Meeting & Educational Conference

Thursday, October 1, 2015 2:30 pm - 3:00 pm

Allocator Track Limited Medical Records and the MSA:

What Do You Do?

Panelist Denise Wrenn, Cleco Corporation

There are many instances where a petitioner has not obtained much treatment over the course of the last two years. If that injured individual meets certain criteria, an MSA could still be appropriate for them, but

the lack of medical treatment could make it difficult to accurately project future medical expenditures. Our expert will discuss some instances that could lead to a small amount of records, and more importantly, steps that

can be taken to prepare an accurate MSA in lieu of this problem.

170

NAMSAP 2015 ANNUAL MEETING

NEW ORLEANS, LA

Limited Medical Records and the MSA: What Do You Do?

Denise W. Wrenn, RN, MSA, CCM, COHN‐S, CWCP, CMSP, ALNC, CLCP, 

• DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

171

OBJECTIVES

1. Discuss (3) major components in providing an exceptional allocation

2. Preparation that should guide your assessment for providing an MSA Allocation

3. What to do when provided with limited medical records

4. Perspectives on Limited medical records on the MSA Allocation

Major Components of an Exceptional MSA

1. Compliance Regulatory

2. Preparedness Data development

3. Communication Education & Advocacy

172

Major Components of an Exceptional MSA

Compliance• Federal Medicare Secondary Payer (MSP) statue and regulations applicable to

workers’ compensation (WC) settlements require that a reasonable portion of the WC settlement be allocated towards future medical expenses (42 U.S.C. 1395y(b)(2(B)(ii)/Section 1862(b)(2)(B)(ii) of the Act) and 42 C.F.R. 411.24(e) & (g).

• CMS may recover from a primary plan or any entity, including a beneficiary, provider, supplier, physician, attorney, State agency or private insurer that has received a primary payment.

• The purpose is to prevent the shifting of the burden from the primary payer to Medicare.

• The requirement is met through the development of a Medicare set-aside allocation report.

Major Components of an Exceptional MSA

ComplianceConsequences of not complying with CMS statue Denial of future medical care Penalties and double damages Suit the claimant, attorney, insurance

carrier Malpractice suit against the attorney Designate its own allocation

173

Preparedness & Data Development

Withstanding CMS’s Scrutiny

• 10.7 Section 35 – Medical Records• First report of injury, medical records of major surgeries, and medical

records for the last two years of treatment, no matter how long ago those last two years were or who paid for the services. Also include depositions from medical providers. Ensure that any “last treatment date” mentioned in the life care plan, carrier letter, or payment history is accompanied by a medical record that matches that date, as well as all medical records for the last two years prior thereto.

• All medical records from all treating physicians for the last two years of treatment for the work-related injury, even if the WC carrier has not paid for the treatment and even if the treatment was long ago. Remember, CMS needs medical records for the last two years of treatment, which may not be within the last two calendar years.

Preparedness & Data Development

Withstanding CMS’s Scrutiny

• 10.7 Section 35 – Medical Records• For example, if the carrier’s records indicate that

the last treatment was in February 2006, then treatment records for February 2004 – February 2006 should be supplied. A statement including that “the claimant has not been treated in the last two years” is not a substitute for medical records for the last two years of treatment. Remember, the information is not for the last two calendar years, but the last two years of treatment.

174

Preparedness and Data Development

Withstanding CMS’s Scrutiny

• 10.7 Section 35 – Medical Records (Cont.)• If you believe the last two years of treatment are unrelated to the work

injury, send those medical records in addition to those related to the work injury, along with any explanation you believe is necessary.

• If the claimant has not been treated by any doctor for any reason within the last two calendar years, CMS generally needs a treating physician to state when the last two years of treatment for any reason occurred, and CMS needs those medical records, too.

• Provide medical documentation (legible recently-dated pharmacy printouts or statement from all treating physicians) that specify medication, strength/dosage, and frequency.

• Provide physician dispense records for cases where the treating physician is dispensing medications that do not appear on the carrier pharmacy printout history

Major Components of an Exceptional MSA

Communication• Allocator

• Educate & Advocacy

• Specific facts and circumstances

• Developments

• Consequences

• What’s your experience?

• Insurers/employer

175

Limited Medical Records CMS Perspective

• CMS has identified specific criteria to be considered in preparing a Medicare Set‐Aside Allocation Report (MSA) and the required documentation that is to accompany the report when submitted to CMS. The required information provides CMS a means to identifying existing liens and assists them in verifying that Medicare’s interests were adequately protected during settlement proceedings.

• If the WC settlement does not contain a reasonable allocation of funds the MSA, CMS will treat the entire settlement as future medical expenses. Medicare will not cover any of the claimant’s future work injury‐related medical expenses until the entire settlement has been exhausted on these expenses.

Limited Medical Records Allocator’s Perspectives • Your practice 

• (Accuracy, do the right thing, be direct, quality product, and follow the rules)

• Ethical

• Repetition

• The Beneficiary

• The Attorney (April‐21‐2003‐Memo)

• Documentation

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What to do with limited medical records

• Review records at time of referral and determine if necessary components are missing.

• Coordinate with referral source request for info • Request an all-inclusive carrier payments history

containing all medical, indemnity, and expense payments made dated within the last six months prior to submission or re-opening. The document must show all payments made by the carrier and include payment date, payee, date of service, and payment amount for at least the last two years of treatment.

• If not received do you complete as is?• Place file on hold until information is obtained.

Limited Medical Records Resources

1. http://www.cms.gov/Medicare/Coordination‐of‐Benefits‐and‐Recovery/Workers‐Compensation‐Medicare‐Set‐Aside‐Arrangements/Downloads/WCMSA‐Reference‐Guide‐Version‐2‐3.pdf

2. http://www.cms.gov/Medicare/Coordination‐of‐Benefits‐and‐Recovery/Workers‐Compensation‐Medicare‐Set‐Aside‐Arrangements/WCMSA‐Overview.html

3. https://public‐dc2.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_7852%27%3EClick%20to%20subscribe%3C/a%3E

4. http://www.cms.gov/Medicare/Coordination‐of‐Benefits‐and‐Recovery/Workers‐Compensation‐Medicare‐Set‐Aside‐Arrangements/WCMSA‐Memorandums/Memorandums.html

5. http://www.cms.gov/Medicare/Coordination‐of‐Benefits‐and‐Recovery/Workers‐Compensation‐Medicare‐Set‐Aside‐Arrangements/Downloads/WCMSATopErrorsandHints.pdf

6. http://www.cms.gov/Medicare/Coordination‐of‐Benefits‐and‐Recovery/Workers‐Compensation‐Medicare‐Set‐Aside‐Arrangements/WCMSA‐Memorandums/Downloads/April‐21‐2003‐Memorandum.pdf

7. http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_07.pdf

177

Questions

Denise W. WrennDenise W. Wrenn & Associates, Inc.

429 Highpoint DriveAlexandria, Louisiana 71303

318‐44‐3153www.denisewrenn.com

denise@denisewrenn.com

178

11th Annual Meeting & Educational Conference

Thursday, October 1, 2015 1:00 pm - 2:00 pm

Legal Track Private Cause of Action

Panelist Amy E. Bilton, Nyhan, Bambrick, Kinzie & Lowry, P.C.

Heather L. Hatch, The Chartwell Law Offices, LLP.

The MSP Private Cause of Action has created a firestorm of controversy over the past year. Our panelists will discuss situations that could lead to a private cause of action, and its effect on the MSP compliance process.

179

Private Cause of Action

Presented by:Amy E. BiltonNyhan, Bambrick, Kinzie & LowryChicago, IL

Heather L. HatchThe Chartwell Law OfficesJupiter, FL

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

180

Overview Of The Law

42 USC 1395y(b)(2)(B)(iii) – Government right to recover

42 USC 1395y(b)(3)(A) – Private cause of action (including doubledamages)

42 USC 1395y(2) ‐‐ Triggers for responsibility

THE PLAYERS

Private Cause of Action

181

The Players

Beneficiaries

Medical Providers

Medicare 

Advantage 

Organizations 

(“MAOs”)

Beneficiaries

Example Cases Allowing Citizen Suits vs. Primary Payer

O’Connor v. Mayor and City Counsel of Baltimore, 494F.Supp.2d 372 (2007)

Estate of Clinton McDonald v. Indemnity Insurance, (2014U.S. Dist. LEXIS 121902, W.Dist.KY, September, 2014).

Bio‐Medical Applications of Tennessee v. Central StatesSoutheast and Southwest Areas Health and Welfare Fund,656 F. 3d 277 (6th Cir. 2011)

182

Medical Providers

Michigan Spine and Brain Surgeons vs. State Farm

Mutual Automobile, 758 F.3d 787 (6th Cir., 2014).

Medicare Advantage Organizations“MAOs”

Old Fashioned Trend: PCA 

does not apply to MAOs?42 U.S.C.A. § 1395w‐22(a)(4)

Nott v. Aetna U.S. 

Healthcare, Inc., 303 

F.Supp.2d 565 (E.Dist.PA, 

2004)

Care Choices HMO v. 

Engstrom, 330 F.2d 786 (6th

Cir., 2003)

183

MAOs, cont.New Trend: PCA applies to MAOs:

12/5/11 CMS Policy Memo

In Re: Avandia Marketing, Sales Practices and ProductsLiability Litigation GlaxoSmithKline, LLC and GlaxoSmithKlinePLC Humana Medical Plan, Inc. and Humana InsuranceCompany, 685 F. 3d 353 (3rd Cir., 2012)

Aimie Collins v. Wellcare Healthcare Plans, 2014 WL 7239426(E.D. La December 16, 2014)

MSP Recovery, LLC v. Progressive Select Insurance Company,2015 U.S.Dist. LEXIS 47784 (11th Cir., April 1, 2015)

Humana v. W. Heritage Ins. Co., 2015 US Dist. LEXIS 31875(March 16, 2015)

Wallace v. National Vision, 2015 WL 3745634 (June 9, 2015)

MSPA Claims 1, LLC v. Liberty Mutual Insurance, 2015 U.S.Dist. LEXIS 114574 (S.D.FL, August 28, 2015).

THE TECHNICAL POINTS

Private Cause of Action

184

Burden of Proof

Is the so‐called “primary payer” obligated to reimburse?

42 USC 1395y(b)(2)(B)(ii)

How can the plaintiff demonstrate the primary payer’s 

obligation to repay?

Defenses?

Court/Board finding?Sufficiency of pleadings?Evidentiary standard? 

Glover v. Liggett, 459 F.3d 1301 (11th Cir., 2006)United States ex rel. Mason v. State Farm Mutual Automobile Insurance Co., No. CV07‐297‐S‐EJL,2009 WL 2486339 (D. Idaho Aug. 13, 2009)

Fisher v. Clarendon National Insurance Co., No. 07‐4092, 2008 WL 191813 at 2 (W.D. Mo. Jan. 18, 2008)

Geer v. Amex Assurance Co. , 09‐11917, 2010 WL 2681160 (E.D. Mich. July 6, 2010)

Nawas v. State Farm Mut. Auto. Ins. Co., 2014 U.S. LEXIS 128365Bio‐Medical Applications of Tennessee v. Central States Southeast and Southwest Areas Health and Welfare Fund, 656 F. 3d 277 (6th

Cir., 2011)Michigan Spine and Brain Surgeons vs. State Farm Mutual Automobile, 758 F.3d 787 (6th Cir., 2014)

185

Statute of Limitations

SMART Act:

Three year statute of limitations that runs from the date of

receipt of notice of a settlement, judgment, award or other

payment.

PRACTICE POINTS –(HOPEFULLY AVOIDING LAWSUITS)

Private Cause of Action

186

Practice Points

• Identify

• Notice

• Add parties

• Contractual waiver

• Usage of trust

• Other options?

THANK YOU!

Private Cause of Action

187

11th Annual Meeting & Educational Conference

Thursday, October 1, 2015 2:00 pm - 3:00 pm

Legal Track State Workers’ Compensation Laws and CMS:

Do They Matter?

Panelists Jennifer C. Jordan, MEDVAL, LLC

Danielle E. Marone, Schmidt, Dailey & O’Neill, L.L.C.

There is an underlying conflict over recommendations and preferences issued by CMS, and state workers’ compensation laws. The dispute can sometimes boil over with direct conflicts that can jeopardize settlements. Our panel of experts will discuss the complexities of this conflict and offer

manageable solutions to the problem.

188

NAMSAP 2015 Annual

ConferenceSTATE WORKERS’ COMPENSATION LAWS AND CMS: Do they Matter?

October 1, 2015

Schmidt, Dailey &O’Neill, LLC

&

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

189

WHICH COMES FIRST?

STATE WORKERS’ COMPENSATION LAWS

OR THE MSP?

State Workers’ Compensation Laws & CMS: Do They Matter?

PREEMPTION DOCTRINE

Article VI of the United States Constitution

This Constitution, and the Laws of the United States which shall be made in Pursuance 

thereof; and all Treaties made, or which shall be made, under the Authority of the 

United States, shall be the supreme Law of the Land; and the Judges in every State shall 

be bound thereby, any Thing in the Constitution or Laws of any State to the Contrary 

notwithstanding.

FEDERAL LAW (THE MSP) SUPERSEDES STATE LAW (AS A GENERAL PROPOSITION)

State Workers’ Compensation Laws & CMS: Do They Matter?

190

SUPREMACY CLAUSE

Amendment X of the United States Constitution

The powers not delegated to the United States by the Constitution, nor prohibited by it to 

the states, are reserved to the states respectively, or to the people.

HOWEVER, COMPENSABILITY UNDER WORKERS’ COMPENSATION IS DETERMINED BY THE LAW OF THE GOVERNING STATE

________________________________________________

THEREFORE, ABSENT THE UNDERLYING LEGAL OBLIGATION TO MAKE PAYMENT, THERE IS NOMEDICARE EXCLUSION 

State Workers’ Compensation Laws & CMS: Do They Matter?

MEDICARE SECONDARY PAYER LAW

42 U.S.C. 1395y(b)(2)(A)(ii)

In general, Payment under this subchapter may not be made, except as provided in subparagraph (B), with respect to any item or service to the extent that—

(ii) payment has been made or can reasonably be expected to be made under a workmen’s compensation law or plan of the United States or a State or under an automobile or liability insurance policy or plan (including a self‐insured plan) or under no fault insurance.

MSP PROHIBITS MEDICARE FROM MAKING PAYMENTS WHERE THERE IS AVAILABLE INSURANCE RESPONSIBLE FOR THE SAME

____________________________________________________________________________

NO DIRECT OBLIGATION FOR INSURER TO DO ANYTHING OTHER THAN MEET ITS LEGAL OBLIGATIONS

State Workers’ Compensation Laws & CMS: Do They Matter?

191

MEDICARE SECONDARY PAYER LAW

42 C.F.R. 411.46

(a) Lump‐sum commutation of future benefits. If a lump‐sum compensation award stipulates that the amount paid is intended to compensate the individual for all future medical expenses required because of the work‐related injury or disease, Medicare payments for such services are excluded until medical expenses related to the injury or disease equal the amount of the lump‐sum payment. 

(d) Lump‐sum compromise settlement: Effect on payment for services furnished after the date of settlement—(2) If the settlement agreement allocates certain amounts for specific future medical services, Medicare does not pay for those services until medical expenses related to the injury or disease equal the amount of the lump‐sum settlement allocated to future medical expenses. 

IN WC, MEDICARE IS EXPRESSLY ONLY EXCLUDED TO THE EXTENT THAT AN ALLOCATION WAS MADE FOR FUTURE MEDICALS 

State Workers’ Compensation Laws & CMS: Do They Matter?

MEDICARE SECONDARY PAYER LAW

42 C.F.R. 411.46

(b) Lump‐sum compromise settlement.

(1) A lump‐sum compromise settlement is deemed to be a workers' compensation payment for Medicare purposes, even if the settlement agreement stipulates that there is no liability under the workers' compensation law or plan. 

(2) If a settlement appears to represent an attempt to shift to Medicare the responsibility for payment of medical expenses for the treatment of a work‐related condition, the settlement will not be recognized. 

YOU CAN’T ALLOCATE NOTHING TO MEDS OR STIPULATE TO NO LIABILITY TO AVOID TRIGGERING THE MSP

State Workers’ Compensation Laws & CMS: Do They Matter?

192

THE CMS’ WCMSA PROGRAM:

• IS NOT GOVERNED BY ANY LAW OR REGULATION, STATE OR FEDERAL

• IS VOLUNTARY FOR ALL PARTIES, INCLUDING CMS

• IN NOT FORMALLY APPEALABLE BECAUSE IT NOTHING BUT THE AGENCY’S INFORMAL OPINION

• IS NOT LEGALLY BINDING UNLESS CONTRACTUALLY STIPULATED TO BY THE PARTIES

• HAS AN INHERANT COST NOT REALIZED BY MOST

State Workers’ Compensation Laws & CMS: Do They Matter?

WCMSA COSTS BEYOND WC

• Average Wholesale Price (AWP) used to calculate Rx

• Surgery pricing based upon most expensive area facility

• Routine services included that will likely never be needed [ex: MRI of TKR, SCS for claimant that refuses implant]

• DME replacement schedule & arbitrary maintenance costs

• Lifetime responsibility of items or services paid only once, in error, to treat a comorbidity prior to related services being possible, despite conclusion of IMEs, AMEs, IMRs, etc. in states where binding, etc.

• No consideration for malingering, fraud, bad docs, etc.

State Workers’ Compensation Laws & CMS: Do They Matter?

DEM1

193

Slide 10

DEM1 Need to reduce font size because it goes beyond page size. Also need to fix "_MEs" - was it supposed tobe "IMEs"demarone, 9/8/2015

194

CMS Approval Represents Worst Case Medical Scenario

• Blind record review – CMS doesn’t question contents and assumes all recommendations will be pursued and all current treatment will continue unchanged in perpetuity

• Treatment projected in formulaic manner consistent with Medicare coverage guidelines – not necessarily representative of claimant’s actual treatment patterns

• Extreme deference to treating physician

• Must include past 24 months of treatment, even if concluded prior to submission

• Any recommendation with the records submitted is fair game even if not pursued (or contradicted or even contra-indicated)

• All medical reports must match payment in carrier’s payment history

• Lack of records regardless of reason is the most problematic – CMS is highly skeptical that anyone stops treating

• CMS will not complete review if requested documents are not submitted, even if they do not existState Workers’ Compensation Laws & CMS: Do They

Matter?

DEM2

SO WHY GET CMS APPROVAL?

[note: if we were tech geeks rather than lawyers, you’d be hearing crickets right now]

State Workers’ Compensation Laws & CMS: Do They Matter?

195

Slide 11

DEM2 Font size issue. Also added some languagedemarone, 9/8/2015

196

SO WHY GET CMS APPROVAL?

CMS approval is obtained because insurers/employers are:

… fearful of the unknown.

… risk adverse.

… want files closed permanently with no possibility of reopening in the future.

… willing to apparently pay anything to be in compliance with the government.

… willing to take CMS at its word that if its opinion if obtained that it will not seek any reimbursements beyond the approved WCMSA amount.

… more than likely totally unaware of just how badly they are misunderstanding and overfunding the risks associated with the MSP.

State Workers’ Compensation Laws & CMS: Do They Matter?

WHY DOES CMS IGNORE STATE LAW? BECAUSE IT CAN.

• CMS is only providing an “informal” opinion as to what the agency believes adequately protects Medicare’s future interests because the act is not required by any law or regulation, not appealable and not actionable if not followed.  

• If funded in this manner, the agency provides its “assurance” that it will not require any additional reimbursement beyond that amount. Note that these assurances are also not governed by any law or regulation. 

• Because this is not a “legal” exercise per se mandated by some law or regulation, the agency is not violating any laws by not adhering to specifically to all state WC laws.  

• It is assumed that if the WCMSA is funded the way that CMS would prefer despite the WC exposure not being that great that it is less likely to fully dissipate prior to the death of the claimant and Medicare will never be faced with related claims.

• CMS’ main concern is the financial preservation of the Medicare Trust Fund and NOT the insurer/employer or frankly even the Medicare beneficiary for the most part

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WCRC ONLY REQUIRED TO SUBSTANTIATE APPLICATION OF STATE LAW

Section 2.1: WCRC is required to substantiate that the information contained in the case adheres to the applicable state’s WC and/or venue’s legal statutory requirement(s).

Section 2.10:  WCRC case reviewer is required to evaluate the case considering the appropriate State or Federal law when making its final determination in those instances where the WCMSA proposal includes court orders or settlement agreements.

NO REQUIREMENT FOR THE WCRC TO INDEPENDENTLY LOOK FOR APPLICABLE STATE WC LAWS OR LIMITATIONS –MUST BE PROVIDED BY SUBMITTER

State Workers’ Compensation Laws & CMS: Do They Matter?

HEARING ON THE MERITS

CMS policy memo Q/As – all state that they will adhere to a decision issued “on the merits” from the appropriate state venue.

“on the merits” = referring to a judgment, decision or ruling of a court based upon the facts presented in evidence and the law applied to that evidence. A judge decides a case "on the merits" when he/she bases the decision on the fundamental issues and considers technical and procedural defenses as either inconsequential or overcome.

HOWEVER, IF MEDICARE’S INTERESTS ARE ADEQUATELY PROTECTED IN A STATE APPROVED WC SETTLEMENT , THEN CMS WILL GENERALLY 

ACCEPT THE TERMS OF SETTLEMENT ABSENT A HEARING 

State Workers’ Compensation Laws & CMS: Do They Matter?

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HEARING ON THE MERITS

WCMSA Reference Guide v2.3 (January 5, 2015)

State Workers’ Compensation Laws & CMS: Do They Matter?

SO WHAT CONSTITUTES A HEARING ON THE MERITS?

Is it a decision “on the merits” if the parties submit medical records, IME reports, etc. and recommend a decision to the judge/commissioner?

In MD it will show as a “hearing held” on the Order/Award; the Commissioner is free to consider all the medical evidence; and free to disregard counsel’s recommendation.  Is this a hearing “on the merits?”

Several examples of federal judges rubber stamping settlements without so much as questioning evidence presented to the court

Does it matter whether the situation satisfies the CMS definition of a hearing on the merits when the claim is 

settled pursuant to state WC law?

State Workers’ Compensation Laws & CMS: Do They Matter?

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RECONSIDERATION?

State Workers’ Compensation Laws & CMS: Do They Matter?

FEDERAL PREEMPTION WILL NOT AUTOMATICALLY TRUMP STATE WC LAWS

Preemption can be either express or implied:

When Congress chooses to expressly preempt state law, the only question for courts becomes determining whether the challenged state law is one that the federal law is intended to preempt.

Implied preemption presents more difficult issues, at least when the state law in question does not directly conflict with federal law. The Court then looks beyond the express language of federal statutes to determine whether:1. Congress has "occupied the field" in which the state is attempting to 

regulate  [i.e., there is "no room" left for state regulation]

2. whether a state law directly conflicts with federal law

3. whether enforcement of the state law might frustrate federal purposes

State Workers’ Compensation Laws & CMS: Do They Matter?

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WC LAWS ARE NOT PREEMPTED BY THE MSP

No explicit preemption contained in the language of the MSP, therefore state law compensability will determine the MSP exclusion. 

Whether there is an implicit preemption is debatable.  

• Enforcement of certain state WC laws, such as capping medical benefits available under WC laws, could frustrate the MSP  [see Georgia 400 week cap].

• If the purpose is to shift the burden of medical expenses to Medicare, then the state law could conflict with the express provisions of the MSP; thereby frustrating federal purposes.

State Workers’ Compensation Laws & CMS: Do They Matter?

DEM3

PRIMARY PAYER APPEAL

If/when CMS seeks reimbursement of a future payment related to the settlement, that initial determination will be subject to an official appeal

CMS will ONLY seek reimbursement of payments actually made

There will never be an action for failure to follow its informal recommendation, or even for inadequately funding an MSA that is based upon a reasonable and defensible methodology

Absent outright fraud, state approved workers’ compensation settlements will trump CMS demands if proper measures are taken

State Workers’ Compensation Laws & CMS: Do They Matter?

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State Workers’ Compensation Laws & CMS: Do They Matter?

Guadalupe Caldera v. The Insurance Company of the State of Pennsylvania, 2‐11‐cv‐321, 

2013 U.S. App. LEXIS 9706 (5th Cir. 2013).

Unrepresented Claimant had a compensable WC claim under Texas law terminated in 

2002 based upon extent of injury defense. 

Claimant then went on Medicare and had 2 surgeries in 2005 & 2006 without first 

obtaining preauthorization, which is a prerequisite for payment under Texas WC law.

Obtained a lawyer and sought benefits / following 2011 Agreed Judgment in which 

carrier stipulated to compensability dating back to DOL, Claimant filed MSP private 

cause of action because Medicare paid for treatment and carrier refused to reimburse.

Holding: carrier not liable for reimbursement under MSP because claimant failed to 

obtain preauthorization, therefore not legally obligated to pa under Texas WC law.

Court found “Congress intended the MSP to complement, not supplant state WC rules.”  

5th Circuit upheld ruling and U.S. Supreme Court denied cert.

MSP CASE LAW

DEM4

State Workers’ Compensation Laws & CMS: Do They Matter?

Morgan v. Villa, 2013 U.S. Dist. LEXIS 49520 (N.D. Ok. Apr. 5, 2013).

Parties filed a motion to allocate settlement funds and sent notice to all lien holders, 

including Medicare, to whom the parties fully intended to pay the $5,788.22 from the 

conditional payment letter in full.

DHHS filed to remove to federal court then moved to dismiss even though not a party

DHHS eventually articulated that it removed this case to federal court to request that 

the court dismiss this case as to the United States only and the case should be 

remanded to the state court, absent the United States, so that "any orders issued by the 

state court will not affect the rights of the United States and the Medicare Program." 

MSP CASE LAW

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State Workers’ Compensation Laws & CMS: Do They Matter?

Bradley v. Sebelius, 621 F.3d 1330 (11th Cir. 2010). 

Estate of deceased sought approval of Florida probate court as to distribution of 

$52,500 policy limits settlement among 10 survivors and the estate

Probate court took demands of each at face value and apportioned directly over all 

(each child alleged $250K in loss of parental companionship) 

CMS refused to accept that its $38,875.08 demand was reduced to $768.20

11th Circuit Court of Appeals ruled that the Florida probate court had jurisdiction to 

make that determination. 

MSP CASE LAW

DEM4

State Workers’ Compensation Laws & CMS: Do They Matter?

Tucker v. Cascade General, Inc., 2014 U.S. Dist. LEXIS 160265 (Nov. 13, 2014). 

Longshore case in which U.S. is a defendant.

Requested an award of $195,643 for past medical expenses and $614,341 for future 

medical expenses.

U.S. objected to past amount given not the amount actually paid, but rather the amount 

billed “prior to any adjustments that were ultimately ‘written off by the doctors’” –

court awarded only $145,537.

U.S.  requested $614,341 life care plan be reduced to approximately $141,810, 

representative of PRESENT VALUE of medical services and only 2 medications. 

Government then asked to “use the medical costs projected by the WCMSA to 

determine future expenses, but for the cost of the seizure medications the United States 

prefers the prices projected by Fountaine in the Life Care Plan.”

CMS had already approved an MSA for $334,840…

MSP CASE LAW

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206

State Workers’ Compensation Laws & CMS: Do They Matter?

In re Arellano, 2015 Bankr. LEXIS 9 (Jan. 5, 2015).

Claimant sought to exempt remaining balance of MSA account from bankruptcy

11 U.S.C. § 541 says that Debtor’s bankruptcy estate includes “all legal or equitable 

interests of the debtor in property as of the commencement of the case” and property 

in which debtor holds only legal title is excluded from the bankruptcy estate. 

Court looked to Maryland state law and determined that a trust had been created due 

to extremely restrictive language in the settlement agreement as to the MSA funds. 

Claimant is holding his MSA in trust for the benefit of his medical providers. 

Note that his medical providers are among his creditors. 

MSP CASE LAW

DEM4

WHAT TO DO

I’ve Let the WCRC Know About a state‐specific situation, but they…. 

• IGNORE IT

• TELL ME I’M WRONG

• KEEP ASKING FOR MORE DOCUMENTATION

Recommendations?  Recourse?

State Workers’ Compensation Laws & CMS: Do They Matter?

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REMEMBER THAT THE WCMSA PROCESS IS VOLUNTARY

Submission of MSAs is Voluntary, therefore adherence to the opinion received in return is also voluntary

• No law, state or federal, requires approval by CMS therefore if the opinion is believed to be in error and CMS has no duty to reconsider, other measures should be considered so long as in compliance with state WC law.

• Recommend that rational for disregarding the CMS opinion be memorialized in the settlement documentation and incorporated into the state approved settlement 

• In states where the state WC agency “informally” requires CMS approval to settle a claim, a hearing on the merits can be sought to demonstrate the error and seek agency approval of MSA contrary to CMS opinion

State Workers’ Compensation Laws & CMS: Do They Matter?

STATE LAW DRIVES SETTLEMENT VALUE / NOT CMS

• Settle based upon state law obligations with an eye towards protecting Medicare’s interests

• The goal is to provide sufficient funds to provide for future medical expenses so that Medicare benefits will not be necessary – A CMS approved WCMSA is not the only solution. 

• Funding CMS approved WCMSA provides no future financial upside potential –advancements in medical treatment, patent expirations, claimant predeceasing life expectancy, claimant finally simply ceasing treatment – Absent a reversionary agreement, no one is sending refunds for unnecessary MSA funds.

• Remember that funding a CMS approved WCMSA with self‐administration may not achieve the desired intent. 

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209

THANK YOU!Jennifer C. Jordan, Esq., CMSP,

MSCCGeneral Counsel, MEDVAL, LLC

410-336-4931jjordan@medval.com

Danielle E. Marone, Esq., CMSPSchmidt, Daily & O’Neill, LLC

410-783-1296dmarone@sdolaw.com

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11th Annual Meeting & Educational Conference

Thursday, October 1, 2015 4:30 pm - 5:30 pm

Weaning and Detox Strategies in the MSA

Panelists Jill Breard, LWCC

Jennifer Doherty, Paradigm Outcomes Dr. Steven M. Moskowitz, Paradigm Outcomes

The cost of prescription medications in an MSA can escalate the projection exponentially. Proper attention must be given to drug use, and

appropriate steps must be taken to successfully eliminate these costly medications from the MSA. Our panelists will discuss tried and true

methods that will help wean the injured individual off of these dangerous medications which ultimately will facilitate a mutually beneficial settlement.

211

Weaning and Detox Strategies

Steven Moskowitz, MDSenior Medical Director, Paradigm Outcomes

Jill Breard, LWCCAsst. Vice President, Claims OperationsJennifer Doherty , Paradigm Outcomes

Director of Clinical Services

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

212

Agenda

• Why? 

– Identify why an injured worker needs weaning/detox

• How? 

– Identify your weaning/rehabilitation strategy

– Define resources needed

• Where? 

– Claims strategies

– Selecting the right provider 

3

Basic Principles and Challenge

4

We often need to build a case with the treating providers

• They do not worry about cost of medications

• The do not necessarily acknowledge a substance use issue

Choosing the ideal setting depends on injured worker’s needs

The process requires close intervention before, during and after

Be careful of cost shifting

• Medication to medication

• Medication to procedures

• Medication to DME

213

■ The Medicare Modernization Act of 2003 (enacted 2006) included pharmacy as a covered benefit 

– Medication costs became a  challenge to settle the claim.

– Direct cost of drugs and indirect (secondary) expenses are incurred

■ The costs for new drugs keeps escalating 

– Hydrocodone/Acetaminophen (generic) at $0.30 pp

– Zydohydro 20 mg  (extended release/crush resistant) at $7.00 pp

– Subsys (Fentanyl Spray ) 400 mcg/spray, $65.00 per spray

■ The medication costs calculate over a lifetime

– Assume a MEDD of 40 mg over a 30‐year life expectancy 

■ The cost over lifetime can be enormous

– Hydrocodone  (generic) $13, 140 

• 10 mg tab, 120 per month

– Zyohydro $153,000

• 20 mg tab, 60 per month

– Subsys $1,423,500

• 2 sprays per day , 60 per month (10 sprays per container)

5

How Opioids Affect the MSA

Dimensions of Opioid Issues

Ineffectiveness 

Opioid Use Disorder Risk and Behaviors

Adverse Medical Effects

Cost

6

A Systematic Approach to Categorizing Opioid Issues

214

Dimension Measures/signs/evidence

Ineffectiveness  Persistent severe disability 

Persistent high pain rating  

Seeking other medications and procedures

Dose exceeding guidelines 

Opioid Use Disorder 

Risk and Behaviors

Premorbid/comorbid substance abuse

Breaking pain treatment agreement

Inconsistent UDS

Doctor shopping

Dose escalation, multiple prescribers

Dose exceeding guidelines 

Lost prescriptions, early refills

Obvious intoxication, overdose episode

Adverse Medical 

Effects

Taking additional meds for side effects (anti‐emetics, laxatives, stimulants, testosterone)

Comorbid medical problems at risk: osteoporosis, substance abuse

Dose  exceeding guidelines

Cost Inappropriate formulation

Inappropriate dose

Excessive dose

Dose exceeding guidelines7

A Systematic Approach to Categorizing Opioid Issues

8

Dimension Measures/signs Actions

Ineffectiveness  Persistent severe disability 

Persistent high pain rating  

Seeking other medications and 

procedures

Dose exceeding guidelines 

Functional assessment (examination)

PT evaluation, OT evaluation , MD 

evaluating

IW functional report

FCE

Vicarious evaluation: driving, 

childcare 

MEDD tracking 

Opioid Use Disorder Risk and Behaviors Premorbid/comorbid substance abuse

Breaking pain treatment agreement

Inconsistent UDS

Doctor shopping

Dose escalation, multiple prescribers

Dose exceeding guidelines 

Lost prescriptions, early refills

Obvious intoxication, overdose 

episode

CAG‐AID

Opioid Risk Tool (ORT)

UDS

State PDMP check

Pharm/PDMP refill history

MEDD tracking 

Adverse Medical Effects Taking additional meds for side effects 

(anti‐emetics, laxatives, stimulants, 

testosterone)

Comorbid medical problems at risk: 

osteoporosis, substance abuse

Dose  exceeding guidelines

Pharm/PDMP tool

List of key medications suggesting side 

effects

Document adverse effects

Cost Inappropriate formulation

Inappropriate dose

Excessive dose

Dose exceeding guidelines

Monitor pharm spend

Monitor Opioid spend

Follow RX change trade‐offs

215

Ineffectiveness:Evidenced‐Based Medicine Does Not 

Support High Dose COT

• According to a major NIH systematic review, there is insufficient evidence to support the effectiveness of long‐term opioid therapy for improving chronic pain, but emerging data support a dose‐dependent risk for serious harms. 

9

■ Lack of long term studies‐‐addiction may develop gradually

■ Some studies show very low levels of abuse in pain patients but most exclude “high risk” patients and did not use Urine Toxicology testing… BUT

– Five (5) studies (1,965 subjects) that used urine testing reported illicit drugs in 14.5% of patients. 

– 20.4% of the CPPs had no prescribed opioid and/or a non‐prescribed opioid in urine.

– Other studies show “aberrant drug use” in 40%

■ (Fishbain Pain Medicine.  2008; 9(4):444‐59)

Opioid Use Disorder

Depends on the study!

10

216

11

But Misuse is Not Necessarily “Addiction”

Substance Use Disorder

Addiction

Abuse

Dependence

Misuse

■ Constipation

■ Nausea 

■ Sedation 

■ Cognitive impairment

■ Gonadal suppression in men and women (testosterone)

■ Endocrine dysfunction

■ Dependence and withdrawal 

■ Immune  system suppression 

■ Impaired healing

■ Injuries and accidents

■ Overdose and death

12

Common Side Effects 

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What Weaning Strategy Do You Need?

 $‐

 $50

 $100

 $150

 $200

 $250

Year1

Year2

Year3

Year4

Year5

Year6

Year7

Year8

Breakdown of Case Costs(Its not just opioids)

Typical Complex Pain Case Spend

What is the MSA Spending Context of the Case? 

Cumulative Spend Pattern on Illustrative Case

Pharmacy (Non Opioid)15%

Pharmacy (Opioid)13%

Surgery/ Facility/ Physician33%

DME and Home Health22%

Other Medical17%

Injury

Source: Paradigm Analytics, based on  10,000 open lost time claims 

7

Incurred M

edical ($000)

14

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■ Engaging the Treating provider

– Why do physicians prescribe opioids? 

– Why do physician not/not care to recognize addiction?

– Why do physicians prescribe treatment they know will not work?

How Supportive to Change is the Patient‐Doctor Relationship?

The “Problematic Patient”

The “Problematic Physician”

15

The overlap between chronic pain, addiction and psychiatric disorders is considerable… 

What Are the Injured Worker’s Issues/Needs?

Opioids

16

219

Chronic Pain and Substance Use Disorder are Both Biopsychosocial Problems

• But many detox‐only facilities do not treat the pain issues driving opioid use 

17

Biological

Nociceptive

Neuropathic

Social

Secondary gain

Workplace dynamics

Psychological

Cognitive distortions

Fear avoidance

Patients and Their Doctors Often Do Not Acknowledge “Addiction”

18

220

Opioids Weaning (and Pain) Strategies 

Medication

Need to Treat the

Whole  Person!

The Bio Psycho Social Context

Behavioral Therapies

Social InterventionsRestoration of Function 

• Maintenance (substitution)

– Many have long supported replacement drug (ex: methadone)

– More recently people are advocating for buprenorphine as a replacement drugs

– Both are opioid agonists 

– People still cheat despite getting RX drugs

• Abstinence advocates say there is too much emphasis on biologics, not enough on behavior

– “Eighty to ninety percent of people who use illegal drugs are not addicts," said Carl Hart, PhD, a drug addiction expert from Columbia University in New York City.

• You need a long‐term plan

• Traditional (e.g. 28 day) detox‐rehab

• Long‐term treatment (often transitions to 

sober living or half‐way houses)

• Therapeutic communities (a form of long‐

term treatment)

• Drug Courts

• 12‐Step and other support groups

• Chronic Pain Management Programs

Medication Treatment for Opioid “Addiction” 

20

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Methadone

• Escalating MED with dose

– Methadone  dose

• 20 mg = 80 mg MEDD

• 60 mg = 600 mg MEDD

• Costs for 30 years 

• Weaning off methadone

Buprenorphine

• Powerful medication

– Suboxone dose of 

• 8 mg/d = 600, MEDD

• 16 mg = 1200 MEDD

– Butrans patch 

• 7.5 mcg = 30 mg MED; 

• 20 mcg = 80 mg MEDD

• Costs for 30 years

• Weaning

Medication Medications are Powerful Opioids

Methadone:Highly supervised clinicsClose monitoring Take‐home privileges earnedRisk of overdoseMethadone specific complications

Buprenorphine Purported to be:Lower OD potentialLess addictive (not)Suboxone has opioid blocker if injectedMore convenient, easy to get from MD

21

Interventional Alternatives to Opioids?

• Spinal cord stimulator

• Intrathecal pain pump

• Ketamine infusion

• Compound creams

22

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Weaning and Detox Trends

23

Local Resources

• Local physician weaning (commitment but no results)

• Local detox facilities

• Cognitive Behavioral Therapy

• Regional resources 

• Functional Restoration Program (chronic pain programs)

Weaning and Detox Trends

24

• Functional Restoration Program

• What it is and what it is NOT

DetoxificationFunctional restoration 

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Why is pharmacy an issue?

Current issues:

Pharmacy utilization – multiple medications

Opioid use – high MEDs

Brand versus generic – price

Physician dispensing – price and control

Compounds – price and effectiveness

WHAT ARE BEST PRACTICES?

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Step Therapy

Utilizes evidence‐based guidelines to define the order of drugs that should be prescribed per condition

Suggest prescribing low‐cost, low‐risk drugs initially

Incrementally move up to higher‐cost, higher‐risk drugs if the patient does not respond.

Source: Conlon, 2014

Utilization Review of Pharmacy

LWCC utilizes the Louisiana Medical Treatment Guidelines in conjunction with our drug plan to proactively review pharmacy requests.

Medications outside of our plan are reviewed by our Medical Services Team through the use of a letter of medical necessity completed by the prescribing doctor.

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Utilization Review of Pharmacy

Letters of medical necessity (LOMN)

Sent to the prescribing doctor to address the medical need for the medication that is outside of the plan

Once a response is received, medical necessity is reviewed by the Medical Services Team.

Facilitates changing medications to a lower‐risk, lower‐cost medication

Facilitates changing medications from brand to generic

Other Triggers for Pharmacy Review

Triggers for when intervention is appropriate

Monitoring MEDs – morphine equivalent dosages

Monthly pharmacy cost

Combination of prescribed medications

Number of physicians prescribing and number of pharmacies used

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Other Triggers for Pharmacy Review

Monitoring MEDs 

High MED is considered at 50–120.

ACOEM suggests that 50 MED is the maximum recommended daily MED.

At this level, there are no functional gains and the patient may have increased hyperalgesia.

Source: Conlon, 2014

Other Triggers for Pharmacy Review

Monthly pharmacy cost

Review average monthly cost of medications per claim. Suggested at greater than $500/month.

Address higher‐cost medications with the prescribing doctor, if there is an alternative.

Tapering before Medicare and settlements due to CMS’s behavior with prescription medications

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Other Triggers for Pharmacy Review

Combination of prescribed medicationsReview for drug interactions and treatment of symptoms from side effects versus the injury

Number of physicians prescribing and pharmacies used

If there are multiple physicians and pharmacies, review to consolidate treatment with one physician and pharmacy. 

Could indicate other unwanted behavior

Seeking Physician Response

In‐depth pharmacy reviews on a claim levelReport detailing all medications and recommendations for tapering/changing medications

Schedule doctor’s conference for face‐to‐face meeting

We have found this to be effective in addressing pharmacy issues with doctors.

Utilize either in‐house or outside nurses to address pharmacy utilizationPeer‐to‐peer phone calls

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Compliance Drug Testing

Most effective on claims that treat with pain management physicians

Completed during office visits periodically to ensure compliance with medications

If not compliant, request that the doctor address the noncompliance

Discontinue medications or discharge from care

Utilize peer‐to‐peer for tapering plan

Tackling egregious billing practicesSingle‐unit billing versus multiple‐unit billing

Results from Pharmacy Reviews

Provides quality care to the injured worker to improve functional ability

Lower cost and opioid utilization

Helps position Medicare‐eligible claims for calculations of MSAs

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pharma review

peer to peer

utilization review

IME not affective (enough)…

37

The Complex CaseWhat happens when claims strategy does not work?

38

Claims Analytic Approach for Appropriate Case Identification

Systematic/ Collaborative approach targets cases with prior year spend exceeding $15,000, and clinical triggers

Controversial Diagnosis 

•Reflex syndrome dystrophy

•Chronic Regional Pain Syndrome

•Post laminectomy, disc disorders

•Myalgia and myositis

Repeated interventional 

procedures that is not providing benefit

•Epidurals, blocks

• Spinal cord stimulator

• Implant or remove spinal cord catheter

• Intrathecal pain pump

Pharmacy

•Narcotics above 60 Morphine Equivalent Dose (MED) at 3+ months after injury

•Polypharmacy

•Multiple prescribers

• Inconsistent urine drug screen

Behavioral

•Reduced functionality

• Increasing maladaptive behavior

•Changes in home support system

•Physician shopping

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39

The Workers’ Compensation industry is challenged by chronic pain cases with a predictable constellation of components, often aggravated by mutually‐reinforcing behaviors on the part of the patient and the treating provider.

Addressing the Pain Problem

High Medical Utilization; “Physician Shopping” Interventional 

Procedures, Often Repeated, 

Without Apparent Benefit

Emergency Room Visits

Declining Functional Status

Disability Conviction

Runaway Opioids/Other Prescriptions; 

Rapid Escalation in Pharmacy 

Cost

Injury with Delayed Recovery

The “Circle of Pain” A System‐Induced Disability System

The “Complex Pain Patient”

The “Non‐Evidence Based Provider”

Source:  Paradigm Analytics

• 51 years old female, who developed chronic pain after a fall at work in 2010; developed cervical sprain and UE pain.

• Despite multiple ESI, RFA, PT and medication management, she was living a sedentary life, dependent on opiate analgesics. 

• Treatment was primarily interventional with additional nerve ablations already scheduled.

• Patient was diagnosed with complex regional pain syndrome.

40

Sandy’s Story

• Past Medical History included asthma, 20 year smoking history, history of ADHD, history of anxiety, obesity

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Sandy’s Story

41

Treatment, treatment and more treatment 

• Multiple sympathetic blocks

• Spinal cord stimulator placed

• Walked using a cane

• Hydrocodone, MS Contin, Gabapentin, Prozac, Soma, Trazadone, Zofran and Colace

• 2010 and 2011:  ER visit for withdrawals for taking medication early and going through withdrawal 

• Severely depressed, anxious

• Severe sleep disturbance

• Pain Pump has recently been recommended

• Inaccurate diagnosis

• High dose opioids

• Escalating polypharmacy

• Severe functional disability

• Escalating procedures

• Poor outcomes

• Case intransigence 

• High behavioral issues

• High MSA 

42

What is preventing this case from reaching settlement?

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43

Systematic Care Management

Integrated and Collaborative Approach to Pain ManagementParadigm’s Complex Pain Methodology

Bio

PsychSocial

Clarification of Diagnosis

Coordination of Care

Pain Behavior 

Intervention

Evidence‐Based Medicine

Functional Restoration Approach

Cognitive‐Behavioral Techniques

Customized and integrated Pain Management Plan developed and executed by the Paradigm Management Team• Physician (Paradigm Medical Director)• Onsite nurse case manager(Network 

Manager)• Clinical expert/ team coordinator 

(Director of Clinical Services)• Centers of Excellence

• Sandra MED is 460 mg per day 

• Treatment includes significant polypharmacy

• Sandra has been on escalating dosages of narcotics since her initial surgery in 2010. 

• Failed attempt at weaning using current provider 

• Sandra has demonstrated psychosocial barriers to recovery (fear avoidance, catastrophizing, symptom exaggeration) 

44

How can detox be accomplished?

2011     2012     2013      2014

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• Indications for a comprehensive pain program: 

• CPS with high dependence on healthcare system

• Severe deconditioning

• Continued use of prescription meds

• Psychosocial sequelae

• Other treatment strategies not working

• Risk of invasive procedures

(Official Disability Guidelines)

45

Evidenced Based Medicine Weaning, functional restoration, cognitive behavioral therapy

Weaning

Strength and conditioning

Cognitive Retraining

MM2

• Diagnosis clarification  and/or  specific diagnosis

• Structure 

• inpatient vs outpatient

• Detoxification  

• including polypharmacy reduction

• Restoration of function

• Program Location

• Local resources 

• Center of Excellence with specific expertise

46

Program Selection Criteria

Injured worker’s needs drive choice

234

Slide 45

MM2 Not sure about what you are trying to get at here...is it when weaning and pain program are indicated? Margo Musante, 8/31/2015

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• Diagnosis was clarified with hands on/detailed physical examination by doctors experienced on CRPS

• Disability conviction was addressed since admission

• Tapering of the medications was introduced on admission and started on the second week after trust was built

• Medication conviction was addressed during admission and reinforced by entire multidisciplinary team

• Functional Restoration achieved with direct involvement with patient (1:1 treatment) for 8 hours per day

• As function improved mood, sleep, endurance improved 

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Sandra’s Outcome

Results

• Before Complex Pain Solutions:$756,358

• After Complex Pain Solutions:  $149,633

• Savings:  $606,752

• % Savings:  80%

48

MSA Savings

The right treatment at the right time

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• Choice of program matters 

• Behavioral change takes time and practice

• Programs provide structure

– Real life requires self structure

– Community re‐entry requires planning

• Durability = appropriate resources

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Pain Program LimitationsWhy is a pain program is not enough?

• Psychosocial Factors:  Significant axis I of II diagnosis

• Social Factors:  no support, family history of addiction or history of worker’s comp, prior incarceration

• MED:  Higher than 60 mg per day at time of discharge

50

Risk of returning to old behaviors Red Flags

• Opioid use disorder/aberrant drug use

• Treating with interventional physicians post program

• Continue to seek “urgent” treatment (ER/ physician)

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• De‐authorization of narcotics

• Close claims oversight to manage urgent visits, physician shopping

• If still on low dose of narcotics, random quantitative UDS

• Consider telephonic or field case management until you successfully reach settlement

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Treating the High Risk Injured WorkerFollowing successful detoxification

To achieve durable change on a current or potentially high MSA, the case must be addressed at 3 levels

• Clarify the diagnosis

• Address cognitive behavioral factors

• Address psychosocial factors

52

ReviewThe Complex Patient

238

Paradigm’s solution results in substantial, independently‐verified results: decreased costs, decreased morphine equivalents and high level of release to return to work.   

The Paradigm Benefit: Our Solution Works

© Paradigm Outcomes, Proprietary 16

Milliman, the nation’s leading actuarial and consulting firm, conducted an independent analysis  comparing Paradigm cases to their proprietary database of similar Workers’ Compensation claims

Emerging Pain Cases(Less than 1 year since injury)

Chronic Pain Cases(More than 1 year since injury; average 6 years since injury)

Release to Return to Work

Release to Return to Work39%83%

Decrease in Morphine Equivalents

Decrease in Morphine Equivalents

74%64%

Conventional CaseManagement

Paradigm

Complex Pain Lifetime Costs

41%LOWER

Clinical outcomes based on 2014 completed Paradigm cases

Release to Return to Work is determined by the attending physician (not by Paradigm)

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11th Annual Meeting & Educational Conference

Friday, October 2, 2015 8:00 am - 9:00 am

ETHICSCase Study: Liability MSAs – Where are we now?

Do They Have a Place in your Settlement?Moderator

Greg Gitter, CMSP Gitter & Associates, Inc.Panelists

David R. Cherry Cherry Injury Law Wayne Fontana, CWCP Roedel Parsons Koch Blache Balhoff & McCollister

The controversial topic of MSAs on liability cases continues to be debated throughout the industry. Some feel LMSAs are appropriate in some cases,

others cringe at the slightest mention of the phrase. Our panelists will present a case study that addresses the role an MSA could play within the

context of a liability settlement.

240

LIABILITY MEDICARE SET-ASIDE CHECKLIST

Presented by:

Dave Cherry, Esq., CMSP;

Wayne Fontana, Esq., CMSP

Moderator: Greg Gitter, CMSP

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self-promotion. Self-promotion will prohibit the speaker from any future presentations.

241

Introduction

Are Medicare Set-Asides a CMS requirement in liability cases?

Centers For Medicare & Medicaid Services (CMS) has raised concerns over properly meeting obligations owed to Medicare in liability cases.

Following the enclosed recommendations will solve many issues before they become a problem.

Training Outline

Lesson 1: Determine

Determine whether or not the claimant/plaintiff is or will be a Medicare Beneficiary as early as possible in your case and/or claim.

Lesson 2: Identify

Identify whether or not Medicare will be paying for future injury related medical expenses from the underlying liability claim.

Lesson 3: Get

Get a copy of the medical reports and determine whether future treatment is necessary and if so, will it be covered by Medicare.

242

Lesson 1: Determine

Has the client paid into social security in the past?

Are they eligible for benefits?

Are they Medicare eligible in the next 30 and/or the future?

Have they applied for SSDI?

Lesson 1: Determine

Asking the right questions at the earliest possible date will help you determine whether or not you should be thinking about an LMSA.

Questions

243

Lesson 2: Identify

Identify at the earliest possible time whether or not Medicare has paid or will be paying for future injury related medical expenses from the underlying liability claim.

Why? So that you can determine what obligation if any

you owe or will owe to Medicare.

Lesson 2: Identify

Benoit v. Neustrom; U.S. Dist. LEXIS 55971 (April 17, 2013).

Liability case: brain injury arising from alleged negligence of correctional facility.

Settled & Plaintiff assumed all responsibility for protecting Medicare.

244

Lesson 3: Get

LMSA prepared - estimated @ $277K-$333K

reimbursement to CMS for past conditional payments & Special Needs Trust in exchange for lien waiver by Medicare.

The only remaining issue was for the Court to determine Plaintiff’s future medical care and whether or not the LMSA can or should be reduced to account for the financial hardship of Plaintiff.

Lesson 3: Get

Court equitably apportioned the settlement figure bc the amount of the settlement was less than the projected LMSA.

CMS declined to participate. However, CMS will allow a reduction if a court of competent jurisdiction orders the same after a review of the merits of the case.

245

Lesson 3: Get

Berry v. Toyota US Dist. Crt. W.D.LA. (January 10, 2015)

Product liability case vs Toyota

Parties resolve pre-trial subject to Court’s determination that Medicare’s interest have been protected

Court finds no MSA necessary where treating doctor says no future medical related to claim needed

QUESTIONS?

Thank you for your time!

David Cherry, Esq.

Wayne Fontana, Esq.

Greg Gitter, Moderator

246

11th Annual Meeting & Educational Conference

Friday, October 2, 2015 9:30 am - 10:30 am

Pharmacy Formularies and the MSAs

Panelists Dr. Steve Feinberg, Feinberg Medical Group

Matthew P. Foster, HELIOSMark Pew, PRIUM

Pharmacy formularies have proven to be effective when created and utilized appropriately. The lack of a specific formulary in the MSA has shown to result in out of control future medical costs that are unrealistic

and unobtainable. Our experts will discuss the benefits of using a pharmacy formulary for MSA purposes, and present evidence supporting that its implementation can achieve effective care for the petitioner while

at the same time limiting costs for the settling parties.

247

Pharmacy Formularies in the MSAsThe CMS Perspective

October 2, 2015

9:30am

2

DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

248

The Panel

• Matthew Foster, PharmD– Senior Clinical Pharmacy Manager– HELIOS

• Steven D. Feinberg, MD, MPH– Board Certified, Physical Medicine & Rehabilitation, Pain 

Medicine– Feinberg Medical Group

• Mark Pew– Senior Vice President– PRIUM

A medication’s place on a formulary evaluates these indicators:

► Is it safe?

► Is it effective?

►What is the cost? Not just acquisition cost, but total cost of therapy (pharmacy and medical)

Formularies

249

Pharmacy Benefit Management Level

►Formularies to drive appropriate selection of medications in injured workers have previously been established at the PBM level

►Serve to drive the appropriate initial use of medications; when medications are not typical first line therapy or related to an injury, a “block” is created to seek additional approval, either at the adjuster, case manager, or UR level

Formularies in Work Comp

First Fill Formulary

Workers’ Compensation Global Formulary

Injury-Based Formulary Client-Custom Formulary

Brief Description A limited set of medications mainly used in the treatment of an acute industrial injury

Medications that are typically prescribed for the treatment of common workers’ compensation injuries

Medications typically prescribed for treatment of specific injuries

Allows client-specific utilization patterns and clinical approaches to determine formulary design

Division Basedon Age of Claim

Only valid until the claim information is received through eligibility

Acute (<42 days after injury) and Chronic (>42 days after injury)

Generally only valid in the acute phase of injury (<42 days after injury)

Acute (<42 days after injury) and Chronic (>42 days after injury)

Required Data Elements

None (prior to eligibility information being received)

Standard eligibility feed Diagnosis codes must be provided, either WCIO/NCCI body part and nature of injury or ICD9 codes. If ICD9 based, only compensable injuries should be provided

Will be determined based on formulary

Benefits Includes medications typically related to initial treatment of workers’ compensation injuries until eligibility information is received. After that, the formulary changes to the client’s selected formulary

Provides medications related to a broad range of injuries typical in workers’ compensation for that particular client, while limiting medications used in chronic injuries to the chronic phase of injury

Provides medications specific only to the compensable injury as communicated by the client; all other medications require authorization

Provides medications related to a broad range of injuries typical in workers’ compensation for that particular client, while limiting medications used in chronic injuries to the chronic phase of injury

Precautions Only valid until eligibility information is obtained

May provide limited access to medications not related directly to the compensable injury

May restrict access to appropriate medications needed to treat injuries that do not respond to initial therapy; compensable injury information must be included in eligibility feed to trigger appropriate injury-based formulary

May provide limited access to medications not related to the compensable injury

Typical Work Comp Formulary Offerings

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►ODG based formularies

– Texas: all “N” drugs require prior authorization (“Y” or unaddressed drugs can be addressed via UR after initial coverage)

– Oklahoma: all “Y” drugs are covered (“N” or unaddressed medications can be addressed after initial coverage)

• Washington: Implemented a state specific formulary (administered by the state) requiring prior-authorization for indicated drugs

• Ohio: Implemented a state specific formulary (administered by BWC) requiring prior-authorization for indicated drugs

State-Based Formulary Offerings

ODG Workers Compensation Drug FormularyDrug Class – Muscle Relaxants

Generic Name Brand Name Generic Equivalent

Status Cost

Baclofen Lioresal® Yes Y $21.93

Benzodiazepines N/A Yes N $12.00

Carisoprodol Soma® Yes N $8.67

Chlorzoxazone Parafon Forte®, Paraflex®, Relax™DS, Remular S™ Yes Y $17.82

Chlorzoxazone Lorzone® No N $571.54

Cyclobenzaprine Flexeril®, Fexmid™ Yes Y $3.25

Cyclobenzaprine ER Amrix® No N $680.00

Dantrolene Dantrium® Yes N $106.93

Diazepam Valium Yes N $2.98

Meprobamate Miltown Yes N $214.72

Metaxalone Skelaxin® Yes Y $205.05

Methocarbamol Robaxin®, Relaxin™ Yes Y $9.94

State-Based Formulary Offerings

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The Implications ofLong‐Term Medication Use

• Prescribing medications most common method that physicians use to treat medical conditions

• Patients expect their physician to prescribe medication to treat their particular malady - especially pain

Treating Medical Conditions

252

• Medication-related problems would rank 5th among the leading causes of death in the United States if they were considered a disease

• Medication use must be individualized - Every person is unique in how they respond to a particular medication

Appropriateness of Medications

• Start low and go slow

• Repeated weaning trials recommended

Medication Rx Principles

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The Workers’ Comp Medicare Set - Aside Arrangement (WCMSA) Reference Guide May 29, 2014 COBR-M5-2014-v2.2

states:

Medication Rx Resourcesfor the WC Review Contractor (WCRC)

The WCRC references evidence-basedguidelines as resources in determiningfuture treatment. Examples includeMilliman and the Official DisabilityGuidelines (ODG).

• Allows for the input of dosage amounts on various opioid analgesics and converts to both individual and total morphine equivalent dosage (MED). Yellow, Red and Black flags are triggered as MED approaches, reaches and exceeds ODG guideline parameters.

Medication Rx Tools AvailableOpioid MED Calculator

254

Medication Rx Tools AvailableProcedure Summary Dosing Parameters

Medication Rx Tools AvailableProcedure Summary Weaning Parameters

255

• Drug interactions - occur when the amount or the action of a drug is altered by another drug– Mixing opioids and psychotropic drugs, particularly benzodiazepines is

problematic

• Medication side-effects are numerous– Can help relieve symptoms but also can cause unpleasant side effects

that at a minimum can be bothersome and at their worst, can cause significant problems

Appropriateness of Medications

• Invasive interventions

• Physical Medicine approaches– Passive modalities

– Active approaches

• Acupuncture

• Yoga, Tai chi, etc.

• Psychological approaches– CBT, Biofeedback, Relaxation training, etc/

Medication Alternatives

256

• Opioid efficacy drops off as tolerance develops

Short-Term vs. Long-Term Efficacy

• Increased medications sensitivity with aging

• More likely to have multiple medical conditions, and to be taking multiple medications

• Medication risks are greater for an individual when multiple medications are taken

• Certain medications carry greater risks than others– Opioids, Benzodiazepines, psychotropics, etc.

Medications in Older Persons

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• Nearly one-third of all prescribed medications are for persons over the age of 65 years

• In general, 30 percent of hospital admissions among the elderly may be linked to an adverse drug-related event or toxic effect from opioids and sedatives

Medications in Older Persons

• Unfortunately, many adverse drug effects in older adults are overlooked as age-related changes (general weakness, dizziness, and upset stomach) when in fact the person is experiencing a medication-related problem

Medications in Older Persons

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• In older persons, the dose should be started low and adjusted slowly to optimize pain relief while monitoring and managing side effects

Pain and Psychotropic Medications

• The American Geriatrics Society (http://www.americangeriatrics.org) provides guidance on the topic of Pharmacological Management of Persistent Pain in Older Persons at the following Internet Web site: http://www.americangeriatrics.org/files/documents/2009_Guideline.pdf

Medications in Older Persons

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The Intersection of MSA’s and Drug Formularies

MSA’s and Drug Formularies

• The logic …• If the treating physician said it …• Or the payer paid for it …• Within the past 2 years …• It’s the treatment * the rated life expectancy

• The same drugs/dosage/frequency forever?

• Really?

• A drug formulary mandates a “pause” moment

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• A ‘N’ drug isn’t always No• A ‘Y’ isn’t always Yes

• The prescriber should validate the medical appropriateness based on EBM• A formulary requires that to happen

• Soma (carisoprodol) in Texas• Scripts decreased by 90%+ on 9/1/11

• Soma (carisoprodol) in Ohio• Scripts decreased by 72%

MSA’s and Drug Formularies

• With no MSA appeal process, your first offer needs to be your “best offer”

• Identify triggers for when to delay the settlement / WCMSA process

• See if money can be curative

• Polypharmacy <> MMI

• Insomnia

• Lethargy

• Atrophy

• Depression

• Sexual dysfunction

• Constipation

• Addiction

PAIN

zolpidem

modafinil

carisoprodol

duloxetine

sildenafil

stool softener

buprenorphine

Opioid

All of this makes the pain harder to 

identify and treat

All of this makes the pain harder to 

identify and treat

fentanyl?

MSA’s and Drug Formularies

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• Adjust the drug regimen before the MSA

• Create a compelling case that history does not predict future• And document everything …

• Epiphany• Accountability• Enforcement

MSA’s and Drug Formularies

Creating an Epiphany

• Must be collegial• Don’t start with Utilization Review or IME

• Sometimes a prescriber will only respond to a peer• PM&R specialty that focuses on function

• Diligent• 3 calls over 3 days does not constitute reasonable effort

• Recommendations should be from Evidence Based Medicine• Even if the jurisdiction doesn’t mandate it

• Get the agreement in writing• Best practice; the treating physician’s signature on their letterhead

MSA’s and Drug Formularies

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Accountability

• Must be consistent• The treating physician should be expecting the call

• Must include accountability• Not just checking … Assertively verifying compliance

• Must provide flexibility• If Plan A isn’t working, help determine a Plan B

• Must connect the dots• Ensure all stakeholders know the plan and concur

MSA’s and Drug Formularies

Customization

• Create a customized formulary per patient• As drugs/dosages change, edit their formulary

• Determine Prior Auth or Block• How will exceptions be handled?

• Edits + Transactions = Strategy• Active engagement tells a good story

MSA’s and Drug Formularies

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11th Annual Meeting & Educational Conference

Friday, October 2, 2015 10:30 am - 11:30 am

Snappy Answers to Common MSP Questions

Panelist Christine McPherson Melancon, EZ-MSA

We’ve all been asked MSP-related questions which cause us to pause and make sure our mouths are not verbalizing the answer we just

said to ourselves in our heads. You are not going to want to miss this presentation that will capture these situations in a humorous light as we

wind down the Annual Meeting and prepare for our travels home.

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Snappy Answers to Common MSP Questions

Format adapted from Al Jaffee’s “Snappy Answers to Stupid Questions”

Christine Melancon, RN, CCM, MSCC, CMSP, CNLCP

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DISCLAIMER: Per NAMSAP guidelines, all presentations must open with identification that the material to be discussed, is that of the presenter and is in no manner to be considered the opinion of the NAMSAP Board or Association. Additionally, the presenter must state in “no manner should this presentation be considered legal advice”. This presentation is provided for educational purposes only, and is not to be a platform for self‐promotion. Self‐promotion will prohibit the speaker from any future presentations.

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"This is the core of Jaffee's work: the idea that to be alive is to be constantly beleaguered by annoying idiots, poorly designed products and the unapologetic ferocity of fate. Competence and intelligence are not rewarded in life but punished. ~ Will Forbis ‐ Journalist

Q: Do I need a Medicare Set‐Aside?

Answer:   I don’t know. Do you???

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Do I need a Medicare Set‐Aside?

• The need for a Medicare Set‐Aside is complex and in my mind doesn’t have a completely right or wrong answer. It is more about decisions and consequence, and one’s “appetite for risk”. 

• Don’t confuse the WCMSA Review Thresholds with the “need” for an MSA. These are two distinct and separate issues. 

• Medicare Secondary Payer Compliance requires legal analysis by the settling parties. 

• A Medicare Set‐Aside is a method of complying with the MSP, but it ISN’T the MSP

• I can guide you to information and discuss with you some of the real world  consequences but I can’t make the decision for you –

Q: I’ve settled my case for 150K. Can you make my MSA total less than $50,000.00?

Answer: I don’t know. Can I ? 

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Q: I’ve settled my case for 150K. Can you make my MSA total less than $50,000.00?

• How serious are the injuries? What are the current methods of treatment? Are there any outstanding surgical recommendations? What co‐morbidities are present? What is the Life Expectancy?

• Has the injured party reached Maximum Medical Improvement (or a level of stabilization) with regard to their care and treatment?   

• Don’t ask me to “force numbers”. This is asking me to compromise my reputation and integrity, and could perhaps endanger my licensures and certifications. The medical records speak for themselves. 

• Furthermore, why are you settling cases without knowing the full extent of your damages?  ? ? 

Question: Real quick, can you give me an estimated MSA amount if I give you the facts of 

the case?

Answer: No. No I cannot.

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• MSAs, if done properly, require a close and thorough scrutiny of the records. 

• MSAs require thoughtful math calculations• There are a myriad of particulars to consider:  DOB/Age or Rated Age, Life Expectancy, Past Treatment Trends,  Current Treatment Trends, Treatment Recommendations Not Yet Undertaken, Has the Injured Party reached MMI,  Type, Dose, and Frequency of Medication,  File Type: Work Comp or Liability, Jurisdiction, location of the Injured Party, Medicare Coverage Determinations and exclusions.  Change one thing, and change the whole MSA Total. 

• None of these things can I analyze “real quick”

Question: Real quick, can you give me an estimated MSA amount if I give you a diagnosis?

Question:  Can you take _______________ out of the allocation?

Answer: 

• Can you provide me with medical records, physician affidavits, depositions, or letters written on the physician’s letter head, and signed by the physician which demonstrate why the _____________ is no longer necessary?

• Can you provide me with research to demonstrate why it would not be covered by Medicare? 

• No? Then No, I cannot.

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I settled my case for $50,000.00 and just found out that my Conditional Payment Demand is 

$186K. What should I do?

Answer: I don’t know, but what you should have done was…………

• Report the case to the COB&R (formerly the COBC) EARLY. This gives them lead time to search through all payments to identify any they feel are conditional. You will have a better idea of what the real number is if you start early.  

• Stop over‐reaching when reporting injuries to the COB&R –No more “skin and contents”. Report what is confirmed to be related to the case. If something comes up later, you can call back and add injuries and conditions to the claim.  Suggesting that everything is a result of accident/injury can spell disaster at the end (if in fact, it was preexisting). 

I settled my case for $50,000.00 and just found out that my Conditional Payment Demand is $186K. What should I do? Well what you should have done was……….

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• Set the record straight: Identify and dispute any conditional payments that are unrelated to your claim. Hire a professional if necessary.  Start Early!

• PAY ATTENTION:  Your client is a Medicare Beneficiary?  What are they doing with their Medicare Card? 

• Hopefully, the Smart Act will put some of this to rest

I settled my case for $50,000.00 and just found out that my Conditional Payment Demand is $186K. What should I do? Well what you should have done was……….

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The End ~

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275 N. York StreetSuite 401

Elmhurst, IL 60126Telephone: (855) MSA-ASSN

Local: (630) 617-5047E-mail: Info@NAMSAP.org

www.NAMSAP.org

Brian S. Bailey - Executive DirectorLisa L. Kennelly - Membership Coordinator

Carrie Murphy - Continuing Education CoordinatorSarah Zenna - Meeting Planner

Jacqueline R. Peiffer - Marketing Communications Cordinator

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