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Workers’ comp update

now that repeal and replace is dead, we can figure out what we missed while contemplating healthcare armageddon.

Workers’ comp

WCRI’s been publishing a flurry of great reports on injured worker outcomes, physician dispensing, opioids, and hospital costs. Sign up for a free webinar on outcomes here.

Coventry’s out with the second part of their work comp Drug Trends Report – download it here. This part deals with the differences between managed and unmanaged pharmacy.  Good video intro by Nikki Wilson too...

HealtheSystems is rumored to be looking to split the company in two, selling off the PBM and keeping the Ancillary Benefit Network business. With myMatrixx setting yet another high point for valuation recently, we’ll have to see if PBM prices remain stratospheric or drop a little closer to earth.

Given the myMatrixx – Express Scripts transaction had a ton of strategic benefit for the acquirer, a similar valuation for Healthe might be a tad optimistic. In addition, a very sizable chunk of the PBM business comes from one payer – the Travelers – a “customer concentration” issue that will give some pause.

BTW, I’m hearing optimism from many work comp pharma buyers about the “new” myMatrixx-ESI combination.  Guarded, but optimistic.


Are you seeing an uptick in Commercial Repayment Center (CRC) demands coming from the Coordination of Benefits & Recovery Program? (COB&R)? A couple clients have mentioned this to me..the concern seems to be CMS is revisiting MSAs and looking for additional funds (I am likely not phrasing this correctly…Rafael, please clarify/correct!)

Physicians work for others…

About 2/3rds of younger physicians are employed.   Overall, less than half of practicing physicians have an ownership stake in their practice.

Finally, here’s a really interesting snapshot of price variation in a wide variety of healthcare markets

2 thoughts on “Workers’ comp update”

  1. While not Rafael, please allow another lowly MSP compliance attorney to throw in my two-cents in response to your statement concerning increased demands from the CRC. I am not aware of CMS’s Commercial Repayment Center utilizing MSAs to drive its Medicare conditional payment recovery, but it is definitely utilizing Section 111 Mandatory Insurer Reporting data to drive its recovery efforts.

    Notably, we have seen where a particular employer or carrier receives increased attention from the CRC through a flurry of conditional payment demands in a short period of time. The demands are based upon the employer or carrier’s reporting of Ongoing Responsibility for Medicals (ORM). In other words, advising Medicare that it is accepting certain medical care stemming from a claim. Once ORM is reported Medicare claims a right of recovery against the employer or carrier for reimbursement of injury related payments by Medicare.

    As this is data driven recovery, employers and carriers can run afoul of the CRC when their reporting data is inaccurate or omitted. We at Tower MSA Partners have seen instances where following full settlement of a case the termination of ORM was not reported. As a result, CMS believes that the employer or carrier is still accepting responsibility for injury-related medical! The result is the CRC issuing a demand for recovery of conditional payments for post-settlement medical care. The good news is all of this can be corrected, but it results in the expenditure of time and money that could have been avoided had the termination of ORM been correctly reported at the time the case settled.

    The bottom line, whether demands from the CRC come in a flurry or only occasionally, review them and make sure the itemized payments for which CRC is seeking recovery are not post-settlement.

    1. Dan thanks very much for your expert opinion. Really appreciate you sharing it with all of us.

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Joe Paduda is the principal of Health Strategy Associates




A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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