In this episode, ADJUSTED welcomes Dan Anders Chief Compliance Officer with Tower MSA. Dan discusses when MSA's are needed and their place in the settlement process.
Season 3 is brought to you by Berkley Industrial Comp. This episode is hosted by Greg Hamlin and guest co-host Matt Yehling, Directory of Claims at Midwest Employers Casualty.
Visit the Berkley Industrial Comp blog for more!
Got questions? Send them to marketing@berkindcomp.com
For music inquiries, contact Cameron Runyan at camrunyan9@gmail.com
In this episode, ADJUSTED welcomes Dan Anders Chief Compliance Officer with Tower MSA. Dan discusses when MSA's are needed and their place in the settlement process.
Season 3 is brought to you by Berkley Industrial Comp. This episode is hosted by Greg Hamlin and guest co-host Matt Yehling, Directory of Claims at Midwest Employers Casualty.
Visit the Berkley Industrial Comp blog for more!
Got questions? Send them to marketing@berkindcomp.com
For music inquiries, contact Cameron Runyan at camrunyan9@gmail.com
Hello everybody and welcome to adjusted. I'm your host Greg Hamlin coming at you from beautiful Birmingham, Alabama and Berkley Industrial Comp. And with me is my co-host for today Matt Yehling, Director of Claims at MEC Matt say hello to everybody.
Matthew Yehling:Hello, everyone. This is Matthew Yehling from Midwest Employers Casualty joining us from St. Louis, Missouri, along the banks of the big, muddy Mississippi.
Greg Hamlin:Always glad to have Matt with us. And I always like to pull them into these type of riveting topics that we have today, which is Medicare set asides. While my company has some experience with it. Matt's operating unit focuses on excess insurance, so they see a lot of these so I thought he would be a good teammate today as we bring in our special guest, Daniel Anders, Chief Compliance Officer at Towers MSA partners. Dan, if you could say hi to everybody.
Daniel Anders:Sure. Hello from the northern suburbs of Chicago where I am.
Greg Hamlin:Excellent. I grew up in Indianapolis, so not too far. Many weekends in Chicago growing up
Daniel Anders:Down on I-65.
Greg Hamlin:That's right. That's right. We lived in Lebanon in but on the way to Lafayette for a while I spent a lot of time on I-65
Daniel Anders:Yeah, the last time I drove down I-65. Were going to North Carolina and we saw about I haven't seen many burning cars, but there were three burning cars along the entire route and separate incidents throughout.
Greg Hamlin:Well, you know, I love my Hoosier State, but sounds like it was a bad week.
Daniel Anders:Yeah I know.
Greg Hamlin:So Dan, how did you end up in compliance and in the insurance industry, I'm sure. In first grade when you had career day, you showed up as a compliance officer at your show and tell is that right?
Daniel Anders:Exactly. Exactly. I had my little junior work comp playing with me and dressed up and ready to go. So no, like, like many it was an unpredicted unpredicted path for me. I'm an attorney. And from an early age, I did think I eventually become an attorney. So that did eventually lead me on on that path. But I would say that the the path to work comp interesting. If you want me to expand on that.
Greg Hamlin:Yeah. So how did you so I assume you went to law school somewhere? Was it in the Chicago area?
Daniel Anders:Yeah. So after I graduated from college, actually worked on a political campaign and thought my future would probably be more politics and government and worked on the re-election campaign of Jim Ryan, who was the attorney general, in Illinois, and this goes back to what 1998 and stayed on there as a once he was re-elected public information officer. So actually, it was in the press office there and was a spokesman for the attorney general's office and you know, all sorts of manners, which was cool. You got to meet reporters and go out to events and represent the office and that was fun. So I went to law school at night for four years, while I worked at the Attorney General's office, and then he decided to run for governor in 2002. He ran against Rhino the infamous Rod Blagojevich tried to sell Barack Obama's Senate seat. Well, unfortunately, he did not defeat Rod Blagojevich. And unfortunately Blagojevich was elected governor. So at that point, I was graduating from law school, I didn't have a job because he was leaving office and friend of mine at the defense firm in Chicago, that did work comp and liability matters, reached out to me and said, why don't why don't you apply? And I actually applied concurrently with the State's Attorney's Office. They're in action wanted to stay in government thought I had go in that direction, but I also applied at this law firm, I took the bar exam and contact state stories office and they said, Well, you know, we don't look at hiring until we know you pass the bar and probably would be November or later. And the law firm contacted me and said, well, we'll hire you today and bring in well, I have I have loans. So those need to be paid. So I started at the firm in Chicago and and did work comp, which meant, you know, obviously, they don't teach that in law school, or at least I don't recall them having a work comp class. Got the fast course and workers compensation at the law firm there. And that's essentially how I ended up in doing this line of work.
Matthew Yehling:Once you get in, you never get out.
Daniel Anders:No, no. Yeah, that's it's here I am today. I know, time goes quickly too.
Matthew Yehling:Tell us a little bit about your company Tower MSA partners.
Daniel Anders:Sure. So, you know, no offense to big corporations, but I love entrepreneurs. And Rita Wilson and Christine Dudley, going in 11 years now, started at Tower MSA. And Rita had reached out to me, and when was that 2016 Now and had been an ExamWorks at that time. And, you know, to talk about what they were doing at Tower and immensely impressed just with, you know, even when they started the company in 2011, it was a fairly mature market, with Medicare set asides, Medicare secondary payer companies. But Rita, who has a pharmacy benefit management background, and really introducing technology looked at MSA is and said, Well, you know, this is a really still paper intensive labor intensive process, is there a way to insert some technology in here and really, just laser focus on Medicare set aside work. And that's, you know, that's essentially what she did in terms of putting a company together that looked at a process that would tie everything together in the Medicare secondary payer process. And, you know, we talked about Medicare set asides, but today, it's Medicare conditional payments, it's section 111 reporting. Now, when I started doing this, back in 2003, it was essentially Medicare set asides. But now all of this is, is really tied together. So getting back to Tower, you know, what was put together here. And what Rita and Christie put together is a company that really looks at mitigating, you know, the problems that are seen with Medicare set asides, often seen and claimed as, as too high MSA is or difficulties getting those MSAs approved by CMS is engaging in that process and making it much easier for our clients terms of including a Medicare set aside, within settlement of their case, you know, not to have to taglines here, but that's really how we look at this is really kind of care cost and compliance, you know, one, you know, certainly looking at ensuring that that Medicare beneficiary injured worker has the the care that they need, but also looking at that in terms of cost, you know, what we can do to mitigate costs? You know, certainly making sure that person still has the care they need. But, you know, are there alternatives? Are there? Are there treatments and medications, such as aren't needed anymore? You know, and can the app be clarified, and then making sure that ultimately, what we do is compliant with the expectations that Medicare has, you know, we tend to be more of a pro submission company, as opposed to others that have gone more along the non submit route. That's, you know, essentially a whole nother topic.
Greg Hamlin:Well, I think what you guys do is fantastic. We've worked with you guys in the past, and we've had excellent results, because I know, some of our guests probably know, a lot of this information and others know, next to nothing. I know, one of our for sure audience members is my mom who probably doesn't know anything about about Medicare. So I thought, let's go back to the beginning, maybe and just explain for somebody who either has had never had exposure to this or has very little exposure to this. What is the purpose of a Medicare set aside? So why why why do we need one? And what's the purpose of that?
Daniel Anders:Yeah, this is this is what I have to give when we my wife, and I meet somebody socially, and they say, What do you do for a living? Right? Well, right. And my wife turns to me and say, you know, can you tell them you're an astronaut?
Greg Hamlin:Right, right.
Daniel Anders:Yeah. So no, and I was talking to some of my colleagues the other day was at a conference and we're all talking about does your mom understand what you do? Or your what my colleague was saying? I think my brother understands, but my kids don't. So I tend to when I lay this out to somebody is you know, most people understand what what Medicare is and providing health benefits for you know, 65 or older, less people know it's also there for free people that meet disability requirements. Also some people have some understanding of Workers Compensation, you're injured on the job that your employer will assist you with providing benefits and cover your care and then try to tie those two together and say, Well, okay, at some point, if you have a workers compensation claim, you may settle your case, if you're somebody that is on Medicare close to being on Medicare, the government doesn't want to get stuck with the bill, for your medical. So if you need a knee replacement down the road, if you need have surgery, if you're on some medications, the government doesn't want to get stuck with the bill. And you as a taxpayer should say, Well, that makes sense. Why should tax money go to something where there's a nother entity out there, that being you know, workers compensation insurance company or, you know, the the employer that you work for that can pay for it? So essentially, what Medicare says is all right, take some of those settlement monies and utilize those for future medical care. So what we do then is free view that persons that injured workers medical records, their pharmacy information, and determine what they will likely need over their lifetime. And calculate that all out and come back with dollar amount that is allocated as part of that settlement. So it could be 10, 15, 20,000 dollars depending on the case, but that money is there to pay for that person's future medicals, and the government doesn't have to pay for it.
Matthew Yehling:The whole process of the MSA, there's a lot of confusion around it. I mean, in this, is there an easy way or a simple way to answer the question of when do you need an MSA?
Daniel Anders:Yeah, I think first one is you need a settlement. You know, if you don't, if you're not going to settle, and when I say settlement- settlement that's going to close out medical, if you don't have that you don't need an MSA. So we need to start with that if you have an injured worker that's looking to settlement, it's might be open to it, then you also need him or her to have some stability within their medical care. And frankly, sometimes we'll get a referral for an MSA for somebody that essentially just came out of surgery. Well, that's a tough one. Because, as you know, usually if someone with just had a surgery is going to have increased medication use, they may have more frequent physician visits more physical therapy, than they're really going to need over their lifetime. So then Medicare says this themselves, you know, they're looking at an MSA for somebody who's you know, MMI, for their care has leveled off, because what they will do is essentially lock in place treatment medications that are occurring for that person's life expectancy. Now, the reality is even somebody whose care is stable, things will change over lifetime. But for Medicare purposes, when they review it, the way they've developed their process is, well, we're just going to, for the most part, lock in that care, so the right time is settlement, and have somebody whose care has has stabilized such that that gives an accurate, as best as possible prediction of what future medical care will look like.
Matthew Yehling:So a follow up to that. So that's when an MSA is needed. We've met mentioned, EMS or the Centers for Medicaid and Medicare Services. And you mentioned earlier the approval process and I don't want to get bogged down in all the minutiae of everything. But when should that MSA be submitted to CMS or Centers for Medicare Medicaid Services?
Daniel Anders:Yeah, well, first of all, you face the question. It's a voluntary review process. So you may decide even if you can submit it, that you're not going to, and people fall on various sides of when to do that, or whether to do it. And I won't get into all the minutia of that right now. But you have you have a choice there as to whether its submit or non submit, the MSA, Medicare only allows you to submit if you meet a certain criteria, so you have to either be a demo injured worker, that's a Medicare beneficiary and a total settlement that exceeds $25,000. Or you have a someone that has a reasonable expectation of Medicare eligibility within 30 months and the total settlement exceeds $250,000. So if you meet any of those, either of those, I should say criteria. Then you can submit the MSA so that that gives the thresholds there There's still a timing element here as to when to submit. And I'd say, again, getting back to making sure that medical care has leveled off. But also that you've addressed any cost drivers on the MSA, any loose ends, you know, at Tower, half of our MSAs receive what we call physician follow up service. So, you know, essentially a free service from us. Because what we've saw, and we've developed this over the years is, we'll get these in and at no, no fault of the adjuster because they look at these differently than we do when it comes to what Medicare wants, but we'll look at the records, and there seem to be medications listed there that that injured worker is no longer on, there's, say a surgery that was mentioned 18 months ago, that is no longer seems to be a recommendation, well, if those are in the MSA, it could be, you know, an excessive amount in the allocation. So what we recommend to our client, and then usually go back to is treating physician, get them to sign off. And it could be a simple statement that, you know, a spinal cord stimulator stimulator is no longer an option. These two medications are active, these two have been discontinued, that not only mitigates the MSA, but it also makes sure that we can get the MSA approved quickly. You know, typically, it takes two weeks to get an MSA approved by Medicare. But I date back to days where it took six to eight months to get one of those approved. So I mean, it's complements to Medicare for bettering that process. But if you don't have all the i's, you know, I's dotted, T's crossed, then Medicare come back and they'll say, well, we need a pharmacy history, we need treatment records, we need clarification. And then that drags the process out.
Greg Hamlin:You made some good points there on making sure that the right information is provided. And I think we hear that all the time garbage in garbage out. And you know, if we don't give the right information to explain what the treatment is, then we're going to get things that aren't actually accurate for their future allocation. So it's really important, I think what you were talking about to make sure that okay, if there are medications listed or treatments discussed, and then we know that's changed, but we're not giving them the information that it's changed, then we're probably going to be surprised on what they're recommending for this person's lifetime care.
Daniel Anders:Yeah, I used to joke with people, I'd say, Well, I can do an MSA if a doctor writes something on a napkin, but it's probably neck and neck.
Greg Hamlin:Right, right. So another element to MSA is that I know gets discussed a lot. And I don't know if everybody understands it is rated ages. And so I thought it would be good to just explain what is a rated age? And how do they play into an MSA? A Medicare, set aside.
Daniel Anders:Yeah, no rated ages are a great thing for an MSA. So it's an age given based on an individual's medical impairments when the effect they have on life expectancy. So actually, I pulled up an example from my friend Kevin Puckett, who, who's owns KP underwriting, which we partner with. And he had a great example here to show exactly how this works in practice. So take a 62 year old male, who has a life expectancy of 21 years has diabetes, it's orally controlled, and hypertension. So based on his assessment, and I should back up so the rate age is either done by an underwriter like Kevin Puckett, or you can go through life companies that will provide these rated ages. So 60 year old male life expectancy of 21 years diabetes, hypertension, decreases life expectancy by four years. So essentially, what that means is the 62 year old becomes a 67 year old, you have a lower life expectancy, so 21 years become 17 years. So that's good. Not good for him good for the MSA. Because now we're allocating that treatment and medications over 17 versus 21 years. And depending on the the allocation, that could be a make a significant difference, you know, for example, with with knee replacements, or any kind of replacements, I mean, we're really looking out maybe 25 years. So, it depending on a person you could actually not need to allocate for a revision surgery, once that rated age comes in, because of that change in life expectancy. So you could eliminate 30-40,000 dollars Just as a result of the rated ages so we essentially automatically do rated ages as with any referral we receive and You know, people like to max CMS over the head over things, but them allowing for the rated ages is certainly a benefit to, to the process.
Matthew Yehling:Yeah. And when I started doing MSA and workers comp, you know, 20 years ago, process was you would reach out to a life company, they would send you back, you know, anywhere from three to five rated ages. And I know, that process has changed for most companies. I would encourage most companies if they're not, if they haven't changed that process, you know, they probably should. And kind of a leading question here. But I know there was a practice where CMS will average out those life expectancy. So if you're getting, you know, a spectrum, right of it's a median. So if they're, if you're given the example of you know, the 62 year old one says he's 67. The other one says the standard, which means he's 62, right? They're going to use a median, and then they're using, say, there's another one in there that says 63. So you're going to, you're going to be using the median versus if you're using one, and a reliable one that CMS has certified the company for, then you're you're kind of working against yourself, I guess, is that the tip there, and I just think, people to work with their MSA company on because you could set that best practice of we want to use Kevin is a good example, or a standard company that that you're going to get a reliable product for, right? That's kind of a loaded question on that process. And CMS has made other changes over time on on rated ages and how they're to be utilized. But it sounds like you're using Kevin, you know, maybe you can speak to how that's changed over time.
Daniel Anders:In terms of the rated ages, yeah, I think like you said, with the life companies, they don't necessarily give very favorable ratings. So you're gonna get a lot better and, frankly, more accurate rating with using, you know, someone like, like Kevin Puckett , and I'm getting that rated age in the MSA.
Matthew Yehling:I was just gonna make one other quick point. And I don't want to get too far into the weeds on this. But I know they, you know, the I guess the misnomer that I hear back from people when we were talking about MSA was that rated age is only good for seven days. And like, well, it does. That's true if you need to buy that that annuity from the life company in the next seven days. Right? You know, just because so there's, I guess, I'm just trying to disconnect the rate of age that a life company is providing for the purchase of their product, which we will write about in a minute versus array to date that you're going to submit to CMS.
Daniel Anders:Yeah. Now, those are, frankly, good for up to three years per Medicare's rules. So we essentially, if we come back in a year, we can just add, and I'll let you add another year to without having to get a new rated age.
Greg Hamlin:That's great. And I think, Matt, you're you're hitting on some of the points. This is why it's such a confusing topic. It's there's so many pieces, and how each party looks at these pieces is what makes it confusing, I think, especially if you don't have a lot of experience doing this. So the next step, I guess is, and we've talked a little bit about this, I think you've hinted at a few things. You mentioned spinal cord stimulators, making sure treatment, they weren't still in the traumatic phase of treatment that their treatment had stabilized, stabilized out. But when should you consider deciding whether it's worth attempting to settle a claim when they're medical or eligible? And when should you probably pump the brakes and wait a little while or maybe not try to settle it based on the case facts? What are some of the drivers that when you look at that these are really going to swing an MSA one way or the other to make that decision whether to move forward right now? Or maybe wait?
Daniel Anders:Yeah, I think you're certainly looking at, you know, are there medications that perhaps are short term that because again, like I said, Medicare will just lack those medications in place for the most part of their person's lifetime. So, you know, I know sometimes there's an urgency to settle out the case. But if it's a matter of waiting three, six months to taper off and remove those medications, that's something else. We look at the MSA, we might make that type of recommendation, if it's a matter of person is going to have a surgery in a few weeks, it might be best to let them have that. And but, you know, even something like that, as as we talk about it, you know, there may be in that it's really a business determination there. If that person needs a surgery, you know, would the carrier rather pay for it upfront or would they rather just fund that as part of an MSA? You know, you can have have a fairly high MSA. But based on your risk assessment, you might say, well, I'd rather just pay that lump it out, or structure it, which another thing you can do with the MSA and get that off my books, because of the risk that things could get worse. And that's something that really becomes, you know, risk management how much you want to spend on resolving that claim. But what we try to do when we get these these files is, you know, initial make a determination, because I know you typically have come to us and wanting to settle the case, are there things that we can do to mitigate that, or to confirm that the MSA that we develop will be approved by Medicare as is so we're looking at what that might be. And again, as I referenced earlier about reaching out to the treating physician, clarifying prescription medications, and more often that we can successfully do that. But yeah, there's ones that are just trouble. There's not much you can do, person is treating immensely. And those are difficult. I just spoke to an attorney yesterday, on a case where a person they she had a back injury and had gone through physical therapy in a period of medications, but now was just going to a treating physician monthly. And the treating physician was is really doing nothing but giving her work off slip every month. And she's been doing this for two years. So from an MSA perspective, and this one is probably not even going to be submitted to Medicare. But I told the attorney, even where we look at these more aggressively when they're not going to be submitted. It's hard for me to reduce physician visits when the person has this continually gotten their monthly for I think it was yeah, it was two years ago and two years, I need some clinical or legal basis to reduce that. But I think it was 53,000 at an MSA. And those those are difficult, we run into situations like that. So we discussed the case. And I think her option was you're actually going to do surveillance and take that back to the treating physician and and see if the treating physician at least acknowledge that monthly visits or perhaps even less, or closing those out is something that's going to work.
Matthew Yehling:I know Greg has a final question that he's going to ask, but I would just you know, say in closing, if there's one thing you could tell us about the demystifying or clarifying anything for anybody out there, that's like, wow, they've talked for 30 minutes now. And I still am confused by what an MSA does and how to submit it or if I should submit it, or the cost drivers. And, you know, we've talked about rating agencies. This is a complicated subject that obviously, like we started, we, we could talk about this for days. And I can geek out about different things about this for a long time. I find it very interesting. The process is, you know, very enlightening. But if there's one thing you could tell people like to help demystify the whole cloud cloud around MSA, you know, maybe share with that, and then I'll throw it back to Greg.
Daniel Anders:Sure. Yeah, I think it's it gets back to the earlier questions you had is really just understanding when that Medicare set aside, maybe appropriate, in a case that you're claiming that you're settling. And from that point, especially if you're newer to the process, and as we talked about, it can get a bit complicated is reaching out to whether that's someone you work with who has specializes, or has experience in this, or working out or choosing reaching out to your MSA partner, Tower, whoever it may be, to provide consultation and this, I always joke with people. I'm an attorney that doesn't bill. So you can call me up email me and which I get all the time and say, here's the scenario I have. Do I need an MSA? How do I reduce cost and this, but utilize the people I do it all the time. And when I don't have experience on something reach out to people that do. And you'll learn more? As I'm sure both of you have over the years? And and get the answers that you need?
Matthew Yehling:I love that answer. You know, you don't have all the information you reach out to the experts that do mean clearly you guys you do and I appreciate that. And speaking with you today, Greg, take it back to you. Thanks.
Greg Hamlin:Yeah, I just think, you know, you've hit on some important things. And I hope what we've accomplished today through our discussion about this topic that can be a little confusing, is if nothing else, hopefully now there's some triggers in people's minds that I need to ask for some more help if I don't understand On this, because obviously the CMS, we start thinking about Medicare, they're looking for ways to fund that. And insurance carriers are an easy way to do that if we're not doing what we should be doing. So this stuff's really important.
Daniel Anders:Yeah, it's kind of like trying to fix the plumbing yourself and water shooting out. And the bad things happening is, that's exactly right. Yeah. Just reach out and ask about what you need to do.
Matthew Yehling:I mean, you mean the internet doesn't always have all the answers. YouTube, show me how to do it. A
Greg Hamlin:That's right. That's right. Well, Dan, I really enjoyed having you on the podcast today. One of the things that I've really wanted to focus on this year, this season, to change things up is to put some good vibes out in the universe. And so I'm asking each of the people we interviewed if they could share a memory of a time that you are truly happy. And what were you doing? And who are you with Dan?
Daniel Anders:I certainly that's a great idea. And it's been wonderful talking to both of you today as well. So this is fairly recent. And it's certainly the happiest moment we've had in some time. Our second son was born on December 30, Charles Patrick, Charlie. So we were, of course, in the delivery room, and he came out and 10 fingers 10 toes, screaming at us. And that just just a wonderful moment. And frankly, he was he was an unexpected surprise for us. So it was just very wonderful for my wife and I and our family.
Greg Hamlin:I totally can relate Dan and I'm I'm still in the the sleepless nights with our three and a half moth old. But I'll tell you, there's nothing better than seeing your your child's smile, especially with you know, the first the first ones and those first few moments. It's what it's all about. It's why we do what we do.
Daniel Anders:Exactly. Yeah.
Greg Hamlin:Apreciate having time with you today, Dan. And, again, encourage people to, if they have questions, reach out to you. Yeah, on this topic. And I know you'll be happy to help and just remind our audience to do write, think differently, and don't forget to care. And we will hope that you'll join us in future episodes that release every two weeks. So until next time, Bye, everybody.