PMSI - Settlement Solutions PMSI - Settlement Solutions

Case ID No Longer Required for MSPR Portal

By , July 17, 2014 10:58 am

CMS has updated the Medicare Secondary Payer Recovery Portal (MSPRP) to no longer require a case ID to retrieve and request conditional payment information. CMS has not yet issued an official alert to this effect, however CMS has provided PMSI with the following statement: “By adding the Date of Incident (DOI) field to the New Case Request page, the user will have an option of entering either the ReMAS Case ID or DOI.  The beneficiary HICN or SSN, beneficiary last name and beneficiary date of birth will still be required.”

PMSI is extremely pleased with this update from CMS as it will allow users to have greater access to using the portal without the need for a Case ID. This will assist settling parties in expediting the conditional payment verification and review process.


DEA Classification Change for Tramadol

By , July 16, 2014 2:34 pm

Tramadol (brand name Ultram) is a centrally-acting “opioid-like” analgesic. It was approved by the FDA in 1995.  Since then, generic, combination, and extended release formulations have also been approved.   Per the PMSI 2013 Annual Drug Trends Report for Workers’ Compensation, tramadol (brand name Ultram and Ultram ER) was ranked number 3 under the top 20 medications by total transactions and number 12  under the top 20 medications by total spend. When it was initially approved by the FDA, it was classified as a non-scheduled medication as it was considered a “safe opioid.”  However, on July 2, 2014, the Drug Enforcement Administration (DEA) published its Final Rule in the Federal Register which reclassified all medications containing Tramadol as a Schedule IV controlled substance due to evidence presented of possible abuse, dependence and diversion.  The Final Rule can be found here.

What are Controlled Substances and How are They Classified?

Controlled Substances are categorized into “schedules.” Schedule I drugs are considered highly addictive with no medicinal purpose, whereas a schedule IV drug has a relatively low potential for abuse, as well as dependence and is recognized for its accepted medicinal use. Prior to the DEA ruling, several states had already taken the initiative to classify tramadol as a schedule IV controlled substance at the state level due to its potential for abuse and addictive properties.  Consequently, the reclassification of this drug to a controlled substance on the federal level is not surprising.

How Will the Reclassification of Tramadol Impact Medicare Set Asides (MSAs)? 

As a controlled substance, prescriptions for tramadol will now have restrictions on the length of time the prescription remains valid and on the number of refills allowed during this time frame.  Previously, a prescription for tramadol was valid for one year from the date it was written with no limitation on the number of refills.  As a controlled substance, prescriptions will be valid for only 6 months from the date they are written with 6 total fills allowed (original & 5 refills).  If only 4 fills are used in 6 months, the prescription is no longer valid and the patient would not be allowed to obtain the remaining two refills.

Due to this change, claimants may need to increase office visits to maintain use of this medication. Urine toxicology screens may also be required to monitor for compliance, abuse, and possible diversion of tramadol. Both will ultimately result in increased costs to insurance carriers as well as the medical portion of MSAs.

The industry may also see a decrease in the number of prescriptions written for tramadol (ex.,tramadol 50mg, $0.08/tab) as it was most often utilized when a physician wished to avoid the prescribing of a scheduled, controlled substance or narcotic medication.  This may lead to the prescribing of alternative medications, which had previously been avoided, to increase.  This could include the different hydrocodone/APAP formulations (ex.,generic Norco 5/325 $0.19/tab or Vicodin 5/300 $1.97/tab, etc) as well as the  buprenorphine tab (ex., 2mg, $4.14/tab) and buprenorphine/naloxone (8mg-2mg, $10.01/tab) products  which are often utilized off-label for pain due to less potential for abuse. There may also be increased utilization of NSAIDs (non-steroidal anti-inflammatory drugs such as Celebrex 200mg, $8.42/cap) to continue to avoid the use of narcotic medications for treatment of pain and whose long-term use could lead to other health issues such as GERD. If this occurs, insurance carriers could see an increase in prescription as well as medical costs depending on which alternative medication is prescribed, which again would lead to an increase in the medical portion as well as the prescription allocation within the MSA.

Due to tramadol’s change in status to a scheduled IV controlled substance, the manufacturers of all products containing tramadol will have to implement changes required for the proper labeling, handling, and storage of tramadol. The DEA has acknowledged they are aware these changes will take time to implement and have given the manufacturers until August 18, 2014 to comply.

PMSI and Progressive Medical will continue to follow any further changes to tramadol’s use and classifications as well as other common drugs in workers’ compensation claims.  As a leader in providing solutions for cost containment, we understand that these changes could greatly impact prescription drug costs in claims.


CMS to Extend Deadline for Reporting SSNs?

By , July 10, 2014 9:19 am

Pursuant to section 204 of the SMART Act, within 18 months of the enactment of the SMART Act (which is July 10, 2014), CMS was required to modify MMSEA Section 111 Reporting Requirements so that an RRE was no longer required to report social security numbers (SSNs) or health insurance  claim numbers (HICNs).  However, within section 204, CMS was provided with the ability to extend this deadline for 1 year periods if the Secretary notifies Congress that without the extension, it would threaten patient privacy or the integrity of the Medicare Secondary Payer (MSP) program.

Now that July 10th has came and CMS has not implemented this change, it is expected that CMS will soon file for the 1 year extension; however, we remain hopeful that CMS will soon implement this provision of the SMART Act.

In the meantime, RREs that are unable to obtain a beneficiary’s SSN have a few options to remain compliant. CMS has provided the industry with a method to document and demonstrate good faith efforts to obtain SSNs from Medicare beneficiaries through the use of a form that has model language created by CMS to request the information required for reporting under MMSEA Section 111. This document can be found here.

Additionally, there is case law precedent in which a carrier refused to tender a settlement due to the beneficiary not providing their SSN (See Seger v. Tank Connection, LLC and Hackley v. Garofano). In these cases, the courts sided with the RREs and required the beneficiaries to provide their SSN so that the RRE could be in compliance with the MMSEA and not subject to fines.

Therefore, if needed, RREs can document their good faith efforts to obtain SSNs and/or bring the matter to court if the beneficiary refuses to provide their SSN. We will keep our subscribers updated on any developments on the SMART Act and any filings by CMS with respect to this particular provision.


CMS Issues Updated WCMSA Reference Guide Version 2.2

By , June 6, 2014 11:06 am

CMS has issued an updated WCMSA Reference Guide. The updated Guide can be found here; however, we have noted the updates below.

CMS has added a section regarding deference to hearings on the merits of a case:

Section 4.1.4:  Hearing on the Merits of a Case:
When a state WC judge approves a WC settlement after a hearing on the merits, Medicare generally will accept the terms of the settlement, unless the settlement does not adequately address Medicare’s interests.  If Medicare’s interest were not reasonably considered, Medicare will refuse to pay for services related to the WC injury (and otherwise reimbursable by Medicare) until such expenses have exhausted the dollar amount of the entire WC settlement.  Medicare also will assert a recovery claim if appropriate.

  • If a court or other adjudicator of the merits (e.g., a state WC board or commission) specifically designates funds to a portion of a settlement that is not related to medical services (e.g., lost wages), then Medicare will accept that designation.

We believe that this newly added section highlights the importance of a hearing on the merits of a case, so long as Medicare’s interests are reasonably considered, and how it can greatly affect the result of a CMS submitted WCMSA. A hearing on the merits of a case can be a great benefit for claims/WCMSAs which may involve legal issues, denied claims and/or body parts, and where the need for future medical treatment (and the extent of that treatment) is contested among the parties.

While this policy is not entirely new and CMS did express in its 2003 memo that it would “generally” honor decisions made by a workers’ compensation hearing on the merits, this is the first time that this policy was mentioned in the Reference Guide. Additionally, the Reference Guide provides more detail than the 2003 memo by stating that Medicare will accept a court’s designation of non-medical expenses in a settlement. Arguably, this would mean that so long as Medicare’s interests are reasonably considered, that CMS could not require MSA funds to exceed what is leftover in the settlement (beyond what the court has designated for non-medical expenses). Therefore, we encourage payers to utilize a hearing on the merits, where available, to resolve these issues prior to submission of a WCMSA to CMS.

CMS deleted the following from Section under physician dispensed drugs: “If the WCRC finds physician-dispensed drugs used for the work injury, these drugs will be included and priced in the WCMSA using the Drug Tables at as linked in Appendix B.

CMS deleted the following which was previously in 10.7, section 35: “If you believe the last two years of treatment are unrelated to the work injury, send those records in addition to those related to the injury, along with any explanation you believe is necessary.” Additionally, CMS revised the following in 10.7, section 35: “If the claimant has not been treated by any doctor for any reason within the last two calendar years, CMS generally needs all treating physicians to state when the last two years of treatment for any reason occurred.  The treating physicians must also state, in writing, the specific condition/injury the claimant was last treated for, and any related therapy.”

Previously, CMS only required one treating physician to state when the last two years of treatment occurred, but now it appears that CMS will require all treating physicians to state when the last two years of treatment occurred. CMS also modified section 10.8, section 40 regarding payment history to require “an all-inclusive payment history (that is medical, indemnity and expenses) from all carriers, third-party administrators (TPAs), employers, pharmacies, and prescription drug suppliers dated within the last six months of submission or reopening of the proposal, showing all payments made (including payment date, payee, date of service, and amount).”

We believe this to mean that CMS is now going to require a full payment history with all submissions, whereas CMS previously used to only require the last two years of payment history. This will likely help CMS identify where and when payments were made over the claim history beyond the last two years. It appears that CMS will still only require the last two years of medical records.

For any questions on the updated Reference Guide, please contact us at:


Panorama Theme by Themocracy