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February 2016 Newsletter
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NAMSAP Quarterly Newsletter 
Volume 9, Number 1                                                                             February 2016

Elmhurst, IL, January 26, 2016: The Board of Directors of the National Alliance for Medicare Set-Aside Professionals elected the following officers for the 2016 year: 

“I am honored to have been selected by my fellow board members to represent them and our association as president,” said Patureau. “I look forward to working with our team of board members, committee chairs, management staff and all NAMSAP members to continue to strengthen our mission as the leading advocate for an efficient and effective Medicare Secondary Payer (MSP) compliance system. Following the steps of previous leaders and that of my predecessor Kim Wiswell, I am committed to promoting and growing our association, providing our members with the educational and networking opportunities they need for professional development as well as bolstering NAMSAP’s strategic goals”.

NAMSAP would like to thank Benjamin M. Basista, Esq., member of the Board of Directors since 2010 and most recently Vice President for his service to the organization. Basista is a shareholder with Dickie, McCamey & Chilcote, PC and Co-Chair of the firm’s Medicare Compliance Group, in which he concentrates his practice. 

Immediate Past President Kimberly A. Wiswell, Director of Operations for MEDVAL, had this to say: “NAMSAP is a better organization thanks to Ben’s time, talent and expertise. Beyond his work on the legislative and bylaw side of the organization, Ben served as the liaison to the Membership Committee and was a consistent presence at all of our events providing his ideas, input, and enthusiasm. On behalf of the NAMSAP board we express our sincere appreciation for his service and wish him the very best in the future.”

In addition to electing officers, the NAMSAP board appointed Rita M. Wilson, CEO of Tower MSA Partners, to the vacancy created by Basista’s departure. Ms. Wilson oversees all business development, sales, marketing and operational activities, IT systems development, and identifies new product offerings in support of MSP compliance. Within NAMSAP, she is Chair of the Communications Committee and a member of both the Data and Development Committee (DDC) and Evidence Based Medicine (EBM) Committee.

“Rita’s knowledge and experience in the industry as well as her commitment to NAMSAP make her an excellent addition to the overall team” said Patureau.

By: Gary Patureau, CWCP, CMSP
Executive Director/COO

NAMSAP Members:
As President of NAMSAP for 2016, I look forward to working with all of you. A prime objective for this year is to increase participation from our membership in the development of goals for the organization. As you all know the strength of any association is its members’ investment in the strategic planning and implementation process. The 2016 Board of Directors and Committee Chairs are reaching out to the greater membership to increase membership, educational programing and professional development opportunities. We need your help to continue to positively influence the evolution of MSP compliance at the federal level.
Below is a description of each committee and its chair/s. We need new volunteers for each committee as we strive to strengthen NAMSAP. Please contact these individuals if you are interested in participating.
Legislative and Case Law Committee
Erin Collins, Co-Chair
Katie Fox, Co-Chair
The committee monitors and evaluates applicable case law and federal and state legislation and regulatory statutes affecting MSP. The committee informs the membership of such developments and occasionally asks for members to contact public officials.

Education Committee
Shawn Deane, Co-Chair
Tom Spratt, Co-Chair
The committee oversees all Alliance educational offerings including the Annual Meeting, Regional Meeting and online education (webinars).
Webinar Sub-Committee
The subcommittee organizes online education on topics of interest. Recent webinars include those on ethics, ICD-10, Medicare Advantage Plans, Evidenced-Based Medicine, among others.
Annual Meeting Site Sub-Committee
Gary Patureau, Co-Chair
Michelle Allan, Co-Chair
The subcommittee organizes the annual Annual Meeting and Education Conference each year. This includes planning the educational sessions and networking opportunities.

Communication Committee
Rita Wilson, Chair
The committee oversees all public affairs including Alliance social media, press releases, and the quarterly newsletter.

Membership Committee
Michelle Allan, Co-Chair
Emily Grocoff, Co-Chair
The committee oversees membership recruitment and member benefits and makes recommendations to the Board of Directors for different initiatives to enhance membership such as the Partner Professionals program.
Data & Development Committee
The committee attempts to bring the MSP industry together through data sharing and support for improved service levels.

Evidence Based Medicine Committee 
Amy Bilton, Co-Chair
Gary Patureau, Co-Chair
The committee develops and distributes information grounded in evidence-based medicine, widely accepted best clinical practice, or criterion which can assist MSA and MSP practitioners in their work.
Liability Committee (New!)
(NAMSAP is in the process of developing this committee and are looking for folks to help us develop it)

2016 Annual Conference - Remember the Allamollocation. 
We ask you to plan to attend this year’s annual conference in San Antonio. The agenda and speakers are outstanding and we hope you take advantage of the best value for training in the business. There is no conference like the NAMSAP conference in this industry. You will receive the latest educational programing in MSA and MSP compliance at a cost that is affordable for all. Don’t forget all of the continuing education opportunities - it makes the conference an incredible bargain.  Please make you plans to support NAMSAP by registering early. The super early bird rate ends March 31!
This will be an interesting year for all of us as the national election process unfolds. We have an opportunity to influence how the results of the election will affect MSP compliance in the future. We must be active in the process or we could regret the results.
Please register for the annual conference, sign up for a committee and reach out to someone that should be a member of NAMSAP and encourage them to join. This is your organization and we need you to help make it the best alliance it can be.


By: Shawn Deane, JD, MEd, MSCC, CMSP
       Assistant Vice President, Product Development
       ISO Claims Partners  

This past July, the Centers for Medicare and Medicaid Services (CMS) announced that a portion of Non-Group Health Plan (NGPH) conditional payment recovery would transition to the Commercial Repayment Center (CRC). As of October 5, 2015, and going forward, the CRC took over recovery against insurance carriers and self-insureds when these entities are identified as the debtor. Debtor status is generally conferred to insurance carriers and self-insureds pre-settlement in Workers' Compensation (WC) and by default in No-Fault (NF) claims.
What Does This Mean for Everyone?
In town hall webinars and in published alerts, CMS indicated that the Benefits Coordination & Recovery Center (BCRC) will continue to maintain recovery against claims established with the BCRC prior to 10/5/2015; and for the indefinite future in liability claims [against the claimant-beneficiary as the debtor].
With respect to the new recovery process, the CRC will transmit Conditional Payment Notices (CPNs) to WC and NF insurers when they've indicated responsibility for medicals (this can occur through ORM reporting in Sec. 111 or via self-reporting). Following the issuance of a CPN, insurers or self-insureds will have 30 days to dispute or respond to the conditional payment charges. If no action is taken in 30 days, the CPN will convert to a demand for repayment.
Key Considerations
The CRC transition is a significant change to the NGHP conditional payment recovery regime. It is important to consider the following changes:
  • CMS may now recover in workers compensation claims pre-settlement. Prior to the CRC transition, CMS typically would only seek recovery following finality to a claim. In the context of workers' compensation claims, this meant a full and final settlement. Under the new process, the CRC can now initiate recovery prior to a settlement.
  • CMS can engage in multiple recovery attempts. So long as an insurance carrier or self-insured remains responsible for medicals in an open claim, and Medicare makes conditional payments, the CRC can engage in transmitting CPNs with associated demands for repayment. 
Practice Pointers
  • Understand what you're dealing with. As the CRC has begun issuing CPNs, it is critical that insurance carriers, self-insureds and MSP practitioners properly identify each type of correspondence so that they can be appropriately addressed. It will be imperative that a CPN is distinguished from a demand or a run-of-the-mill conditional payment letter (CPL); as each of these pieces of correspondence carries with them separate obligations and timeframes for action.
  • Act promptly. CPNs carry with them a requirement to dispute or respond to the notice within 30 days or otherwise they'll convert to a demand. 30 days doesn't leave much time to respond to a potential demand for repayment.
Rita M. Wilson
       CEO, Tower MSA Partners

The implementation and use of a drug formulary is lining up to be one of the hottest trends in the workers' compensation system in 2016. Based on the four states that currently have them, formularies can reduce the use of risky medications, improve outcomes for injured workers and lower costs for payers - clearly, a win-win for all stakeholders.
Formularies are not a panacea, say advocates. But when used in conjunction with other measures they can be one of the most effective tools to address pharmacy misuse and cost issues in workers' compensation.
The formularies are not meant to prevent patients from getting needed medications, say supporters. Rather, they aim to ensure injured workers are given the most appropriate drugs for first line therapy, based on their medical conditions.
Tennessee and California are the latest states nearing implementation of drug formularies. Legislation approved in California requires the state to come up with a plan by July 2017. In Tennessee, a legislative committee is slated to review a proposed formulary and, if approved, it could take effect as early as late February.
State Activity:
Four states - Texas, Oklahoma, Washington and Ohio - have formularies in place.  Several other states are also looking at creating drug formularies, either through legislation or regulatory action.
While not all states will embrace the idea of a drug formulary, supporters believe many will. Here's a rundown of where things stand in several states:
  • Arizona:  Regulations described as limited in scope are in the final stages of being promulgated. Enforceability is questionable, however, since pre-authorization is not mandatory.
  • Louisiana:  A bill is expected to be introduced in the legislature this year. Following a failed attempt to pass a drug formulary last year, the director of the Office of Workers' Compensation sought action through regulation and had developed a proposed formulary. With the election of a new governor, it remains to be seen whether the proposed rule will be advanced.
  • Michigan:  Stakeholder outreach is complete and advisory committee meetings have been conducted. The issue is expected to be on the calendar for this year.
  • Montana:   Expected to revisit the issue this year, after a failed legislative attempt last year. 
  • Nebraska:  Expected to reconsider the issue this year.  
  • New York:  Potential use of a drug formulary concept is under consideration by the legislature. 
  • North Carolina: The state's Industrial Commission is required by legislation to conduct a study of the potential impacts of a drug formulary for injured state employees. There are rumblings the study may be expanded to other employees.
Additional states that have discussed the idea of a formulary include Arkansas, Georgia, Maine, New Mexico, Pennsylvania and South Carolina.

Formularies can be either open or closed, and may be based on a commercially available product or developed from scratch.
Closed formularies consist of a list of medications that require prior authorization for reimbursement in the workers' compensation system. All drugs not on the list are considered acceptable as first line therapy. That system differs from the Medicaid type of formulary, which includes a list of approved drugs and requires prior approval for medications not on it.
Both the Official Disability Guidelines created by the Work Loss Data Institute, and the American College of Occupational and Environmental Medicine have formularies that can serve as a basis or the design of a formulary. The proposed formulary in Tennessee, for example, is a hybrid of the ODG guidelines and the state Department of Health Chronic Pain Guidelines.
Tennessee's proposed guidelines require prior approval for all compound and topical medications to correct what some see as a flaw with the Texas formulary (Texas was the first state to implement a formulary). Compound drugs that consist of multiple medications can be prescribed without prior approval in Texas - as long as all the ingredients in the compound are acceptable. When industry experts began to see a significant increase in the prescribing of compound medications, at unreasonably high costs, they surmised some physicians were unnecessarily ramping up the use of compounds.
The idea behind the use of a drug formulary is to ensure that an injured worker gets the right treatment at the right time. The formulary should be based on scientific evidence, thus offering the best chance for the patient to get the most appropriate medication for his medical condition.
The overprescribing of some medications, notably opioids, is expected to decrease when a drug formulary is in effect. Evidence out of the states with formularies in place show that to be true.
There is also research clearly showing that treating physicians change their prescribing patterns because of drug formularies, and are more inclined to prescribe medications they know will be approved. Ideally, the formulary should include a clear, simple method to challenge the use of a medication requiring prior approval when warranted.
Formularies also empower physicians by giving them a reason to deny unnecessary medications to a patient, without fear of losing the patient's trust. 

As stakeholders in many jurisdictions consider whether and how to implement drug formularies for their workers' compensation systems, experts say there are several key factors for success.
  • Work with all stakeholders. Advocates point to Texas as a case study where representatives of all facets of the workers' compensation industry provided input as the drug formulary was being developed.
  • Include compound medications in the list of medications that require prior authorization.
  • Have a strong Utilization Review process. Advocates say otherwise it's like having a speed limit with no enforcement.
  • Base the formulary on scientific evidence; whether it is one of the commercially available formularies or a team of medical experts using solid research to create it.
By: Rasa Fumagalli JD, MSCC
      Director of Compliance,  NuQuest
Opioid pain relievers continue to play a significant role in the national overdose death rate. According to the January 1, 2016 Centers for Disease Control and Prevention (CDC)   Morbidity and Mortality Weekly Report, approximately 47,000 deaths in 2014 were related to overdoses from opioid pain relievers and heroin. This figure represents a 6.5 percent increase from the opioid overdose deaths reported in 2013. Drug overdose deaths were identified by analyzing the National Vital Statistics System mortality files that classified the drug overdose deaths using the International Classification of Disease, Tenth Revision (ICD-10) codes. The most common drugs involved in the overdoses were the natural and semisynthetic opioids, such as oxycodone and hydrocodone.

Although the national opioid overdose death rate is alarming, the US Department of Health and Human Services has been working on developing strategies and initiatives to address this issue. The Centers for Medicare and Medicaid Services' (CMS) opioid overutilization policy, designed to   to curb inappropriate prescribing of opioids is one example of the initiatives underway.

Implemented in January of 2013, CMS' opioid overutilization policy relied upon an all-inclusive morphine equivalent dose (MED) approach to help Part D sponsors distinguish high risk beneficiaries. The use of more than 120 mg of MED for at least 90 days in a row, from more than three prescribers and three pharmacies, placed the beneficiary in the potential opioid over utilizer category.  CMS required its Part D plans to provide quarterly reports identifying these high risk beneficiaries and the results of their review of each case.

Additional efforts to curb opioid abuse were outlined by U.S. Health and Human Services Secretary, Sylvia Burwell in a press release on March 26, 2015.  She identified three key areas that would be targeted by the HHS Department. The areas would focus on: "providing training and educational resources, including updated prescriber guidelines, to assist health professionals in making informed prescribing decisions," "increasing the use of naloxone" and "expanding the use of Medication-Assisted Treatment (MAT)" to treat substance use disorders. These initiatives are evidence medicine based.

CMS has been moving forward with efforts to assist health care professionals in making informed prescribing decisions. Its September 28, 2015 press release announced its "Part D Enhanced Medication Therapy Management Model." The goal of this model is "to test strategies to improve medication use among Medicare beneficiaries enrolled in Part D." The test will begin on January 1, 2017, run for a five year period in five different regions with a focus on the coordination of medication management therapy between the beneficiary, prescribers and pharmacies.

CMS also announced the release of a Part D Opioid Drug Mapping tool on November 3, 2015.  This interactive online tool allows the geographic comparison of the percentage of opioid claims within a local area to other communities nationwide. The data used in the mapping tool is based on the Medicare Part D claims filed in 2013.  According to CMS Director Tom Frieden, M.D., M.P.H, "This mapping tool will help doctors, nurses, and other health care providers assess opioid-prescribing habits while continuing to ensure patients have access to the most effective pain treatment. Informing prescribers can help reduce opioid use disorder among patients." (CMS News Release, November 3, 2015)

Additional training for the proper use of opioids will also be provided to federal health care professionals. President Obama's October 21, 2015 Memorandum for the Heads of Executive Departments and Agencies stated: "The training of Federal health care personnel in appropriate prescribing of controlled substances should be a model for similar initiatives developed across the country." He also ordered improved access to Medication-Assisted Treatment for opioid use disorders. Since inappropriate prescribing practices contribute greatly to the opioid epidemic, the push to modify them should result in a measurable reduction in the 2015 national opioid overdose death rate.
Heather Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP
       Chief Legal Officer, Franco Signor, LLC

The SMART Act, enacted on January 10, 2013, requires the Centers for Medicare and Medicaid Services (CMS) to continue to assess and reform certain aspects of the Medicare Secondary Payer Act (MSP) over time. We recently had two developments from CMS out of the SMART Act: 1) CMS has now made a functionality available via the Medicare Secondary Payer Recovery Portal (MSPRP) which will allow parties to obtain a final conditional payment demand prior to a final settlement, judgment, or award, and 2) CMS has assessed its threshold for liability settlements and determined that the current threshold of $1000 settlements or less do not require conditional payment reimbursement or reporting to CMS. Let's further delve into both developments and discuss any current or future impact it may have on claims handling.  
Pre-Settlement Final Demand Functionality
Recently CMS announced that it has gone live with its pre-settlement final demand functionality as of January 1, 2016. This is an exciting development in theory for parties to be able to obtain a Final Demand prior to settlement if CMS is notified 120 days or less that settlement is anticipated. The SMART Act provides that CMS must be given at least 65 days' notice prior to the settlement, judgment or award.

However, the recent alert from CMS describing the process provides some limitations to using this functionality. More specifically, CMS has elected to limit parties to one (1) download only from the Medicare Secondary Payer Recovery Portal (MSPRP) to secure a final conditional payment amount. It was hoped that CMS would recognize that circumstances change during the negotiation of a settlement, and allow for an additional download, so long as it was within the 120 day period.  Regrettably, this was not the course of action taken, and parties must be careful in navigating this requirement to protect itself from additional conditional payment demands by CMS or any of its recovery contractors.  Should the parties fail to secure a settlement within three (3) business days from download, then the parties only option would be to secure a Demand Letter after settlement through methods that existed prior to this new feature being implemented. 
Further limiting this new process, is the added CMS requirement (which was not part of the SMART Act) requiring parties to submit settlement information through the MSPRP within 30 calendar days of its occurrence.   If the second CMS rule is not met, the downloaded pre-settlement demand would no longer be valid as the parties would be subject to additional conditional payment demands.   The only way to avert this, if the deadline is not met, would be to resort to the traditional methods of securing a Demand Letter from the CMS recovery contractor post-settlement.

The timelines provided by CMS to use this functionality are stringent; therefore, it is imperative to make sure the following process is followed closely.  The milestones that must be tracked are follows:
  1. Notice to CMS that settlement will occur within the next 120 days;
  2. Monitor for conditional payment obligation availability and amount;
  3. Dispute if necessary unrelated charges, within the eleven (11) day time-frame;
  4. Monitor for updated amount and warn if 120 day time-frame will be exceeded;
  5. Download final demand amount, if and only, settlement is imminent within the next 3 business days; and
  6. Upload settlement information to the MSPRP within thirty (30) days of that settlement.
It is important to understand that CMS is providing a single shot at this process, thus it must be used carefully.  More importantly, the parties should agree who will manage this process, as CMS has not made that clear, consequently, if it is available to all parties.  As time goes on, the kinks in this process will hopefully be worked out. Any developments/changes that would be helpful in this process should be communicated to CMS by stakeholders in our industry.

Liability Threshold Maintained at $1000
As part of Section 202 of the SMART Act, CMS is required to annually compute a threshold amount in which liability insurance (including self-insurance) settlements are exempt from MMSEA Section 111 reporting requirements as well as from the requirement to reimburse conditional payments to Medicare. In 2013, CMS announced that the threshold would be $1000 effective January 1, 2014. CMS was to re-review this annual threshold amount by November 15th of each year, with the new threshold to become effective January 1 of the following year.
On October 19, 2015, CMS released an alert stating that the threshold amount will remain $1000.
The alert provides the computation methodology that CMS utilized to ensure that Medicare's recovery exceeds its costs in collecting the claim. More specifically, the alert states that "Medicare incurs costs to perform these activities. These costs include compiling related claims, calculating conditional payments, applying reductions, sending demands, providing customer service, etc. In addition to CMS' costs associated with pursuing recovery, Medicare does not usually recover the full amount of the conditional payments. For example, there may be reductions to the demand to account for procurement costs (attorney fees and costs) or for full or partial waiver of recovery if certain criteria are met. Implementing a threshold allows CMS to use its resources wisely." CMS' computation found that the average cost of collection was $420 per case. Additionally, the settlement amount range that had the demand amount closest to the $420 cost of collection was for settlements above $750 and less than or equal to $1000. The average demand amount for this range of settlements was $436. Therefore, CMS determined that it should maintain the $1000 threshold.

While many may have hoped that this threshold would increase due to inflation over the past two years, it appears that the calculations that CMS undertook wholly make sense. At some point in the near future, it would make sense that this $1000 threshold amount would increase. As CMS must re-assess this threshold annually, plan to keep an eye out for any changes in this threshold as the end of 2016 nears.


The election for the National Alliance of Medicare Set-Aside Professionals (NAMSAP) occurred from early November until December 4, 2015. The Board of Directors, upon the consultation and involvement of its subsidiary committees, sets and implements policies and charts the general direction of the alliance in general while also ensuring proficient management. 88 voting-eligible members cast a ballot online. According to the NAMSAP bylaws (last amended 12/18/20141), the election results would determine the three (3) Category One (1) Directors for a three (3) year term beginning January 2016. Per the bylaws, a fourth seat that became vacant and was filled by board appointment is also up for election. 
The following individuals were reelected:
  • Shawn Deane, JD, MEd, MSCC, CMSP
    A Medicare compliance attorney, Deane serves as the Assistant Vice President of Product Development at ISO Claims Partners and as NAMSAP’s Education Committee co-chair and head of its Webinar Subcommittee.
  • Christine Melancon, RN, CCM, MSCC, CNLCP, CMSP
    Melancon, a nurse and MSP compliance consultant, is a founder, Operations Vice President, and Co-Managing Director for EZ-MSA. She is completing a term as an officer on the Board of Directors, serving as Secretary this year.
  • Gary Patureau, CMSP, CWCP
    The Chair of NAMSAP’s Evidenced-based Medicine Committee and a co-chair of the Annual Meeting Subcommittee, Patureau serves professionally as Executive Director/COO of the Louisiana Association of Self-Insured Employers (LASIE).
  • Kimberly A. Wiswell, CMSP
    Wiswell, NAMSAP’s current President, is active in workers’ compensation managed care and serves as the Director of Operations for MEDVAL. As President for the last year, she has participated in many of the standing committees and serves as the board liaison to the Communications Committee.

“NAMSAP continues to sharpen its focus as the leading advocate for an efficient and effective MSP compliance system and serving as the industry resource and expert of the MSA practice. Additionally, we also promoting a multidisciplinary approach to the MSA practice and are vigorously working to bring additional individuals and companies into the Alliance. If your career involves MSP and you are an attorney, nurses, settlement planner, or claims professional, we invite you to join us.” said Executive Director Brian S. Bailey. 

NAMSAP Committee News

Annual Meeting Subcommittee
Annual Meeting Subcommittee NAMSAP’s Annual Meeting Subcommittee has been hard at work planning the 2016 Annual Meeting & Educational Conference. Led by Co-Chairs Michelle Allan, Esq. and Gary Patureau, CMSP, CWCP, the subcommittee has secured a location and developed an excellent agenda. Presently, they are securing speakers to present on wide-ranging topics associated with MSP, MSA, etc. Access the agenda by clicking here. For more information on registering for the Annual Meeting click here.  


Membership Committee

The annual NAMSAP membership renewal campaign began in early November. Over the course of six weeks, personalized letters from NAMSAP officers and the Executive Director were e-mailed to the membership. More than 125 individual professional members renewed during this time taking advantage of a 10% membership dues discount. Members are encouraged to renew their memberships as soon as possible so there will be no interruption in benefits (webinars and the newsletter, for example) and services (NAMSAP Listserv). To renew your membership dues online, sign in to the members’ only section of the NAMSAP website. You can renew over the phone with your credit card by contacting NAMSAP Membership Coordinator, Lisa Kennelly at (630) 617-5047, outside IL (855) 677-2776. Membership concerns and questions can be emailed to Lisa at

The Annual Conference Committee has been working hard for months to deliver a great meeting for our membership. The conference is set for San Antonio Sept 24-26, the Agenda is set and a number of speakers are already set.. With the famous RiverWalk venue and a great program, including an invited CMS guest, it will be a conference you will not want to miss.

The Webinar Subcommittee has plans to deliver five to six Webinars this year and will seek input for topics of interest to all.

The NAMSAP Communications Committee would like to encourage you to submit an industry-related article for our upcoming newsletter. We are accepting submissions in the following categories: Legal, Legislative, and Medical. If you are interested in contributing to one of these categories, or have an idea for a new category, please contact Rita Wilson, Communications Committee Chair. She can be reached by email at

Click here for past Newsletter editions!

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