Comments (0)

By Settlement Solutions, November 28, 2011 5:40 pm

On July 5, 2011, CMSCenters for Medicare and Medicaid Services began pilot testing a program for the new Workers’ Compensation Medicare Set-Aside Portal (WCMSAPWorkers' Compensation Medicare Set-Aside Portal). Pilot testing of the WCMSAPWorkers' Compensation Medicare Set-Aside Portal has now been completed and CMSCenters for Medicare and Medicaid Services will be conducting a Town Hall conference call on November 29, 2011 from 1:00 to 3:00 pm (EST) to introduce the initiative to all submitters of proposed Workers’ Compensation Medicare Set-Asides (WCMSAs). During the conference call, CMSCenters for Medicare and Medicaid Services will answer questions regarding the WCMSAPWorkers' Compensation Medicare Set-Aside Portal. Submitters who wish to utilize the WCMSAPWorkers' Compensation Medicare Set-Aside Portal must first register and complete account setup.

After the Town Hall conference call, CMSCenters for Medicare and Medicaid Services will post links to the WCMSAPWorkers' Compensation Medicare Set-Aside Portal application and Computer Based Training (CBT) Modules on the WCMSAPWorkers' Compensation Medicare Set-Aside Portal section page under “Related Links Outside CMSCenters for Medicare and Medicaid Services.” The call in information for the WCMSAPWorkers' Compensation Medicare Set-Aside Portal Town Hall teleconference is:

• Call in time: 1pm to 3pm
• Call In Line: 1-800-603-1774
• Conference ID: 29840615

PMSI was invited to participate in the pilot, along with select other submitters, and we have successfully submitted multiple claims via the WCMSAPWorkers' Compensation Medicare Set-Aside Portal. Implementation of the WCMSAPWorkers' Compensation Medicare Set-Aside Portal should improve the overall process by reducing turnaround times and the general delays experienced with the manual submission method. Users will be able to electronically submit the case as well as check the status and location of files. Receipt of the Case Control Number (CCNCase Control Number Number assigned to a file when submitted to CMS for review) will be immediate and all correspondence for cases submitted through the WCMSAPWorkers' Compensation Medicare Set-Aside Portal will be accessed through the portal rather than U.S. mail.

A couple of notable changes to the overall process are:

• The WCMSAPWorkers' Compensation Medicare Set-Aside Portal will not accept cases that do not meet the review thresholds (the proposed total settlement amount is required to submit the case)
• When CMSCenters for Medicare and Medicaid Services issues a developmental letter requesting additional information, submitters will only have 10 business days to respond prior to the case being closed by CMSCenters for Medicare and Medicaid Services

PMSI feels that the WCMSAPWorkers' Compensation Medicare Set-Aside Portal is an enhancement to the WCMSAWorkers' Compensation Medicare Set-Aside submission process. The intent behind the WCMSAPWorkers' Compensation Medicare Set-Aside Portal is to provide better access to information pertaining to submitted cases and to allow for an improved experience when submitting MSAsMedicare Set-Asides to CMSCenters for Medicare and Medicaid Services. PMSI recommends that any organization or individual who frequently submits WCMSAs consider utilizing the portal.

Comments (0)

By Settlement Solutions, November 22, 2011 4:46 pm

On August 5, 2011, we discussed that with the transparency of claims being reported to Medicare via MMSEAMedicare Medicaid and SCHIP Extension Act Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting , we have seen an increase in the instances of improper denial of coverage to Medicare beneficiaries.

This appears to be a widespread problem which is affecting not only the Medicare beneficiary, but the entire insurance industry. For our August 5th blog posting, please click here.

On November 16, 2011, CMSCenters for Medicare and Medicaid Services held a teleconference for liability insurance (including self-insurance), no-fault, and workers’ compensation, collectively recognized as Non-Group Health Plans (NGHPNon-Group Health Plan - liablity (including self-insurance), no-fault and workers' compensation), to address MMSEAMedicare Medicaid and SCHIP Extension Act Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting technical issues. Several callers, including industry associations as well as insurance carriers, took the opportunity during the question and answer session to express their frustration to CMSCenters for Medicare and Medicaid Services regarding the issue of beneficiaries being inappropriately denied coverage due to the improper handling of information supplied during Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting reporting. The amount of discussion surrounding this issue confirms that it is a widespread issue and it was made very clear to CMSCenters for Medicare and Medicaid Services through these discussions that this is a very important issue requiring CMSCenters for Medicare and Medicaid Services’ immediate attention.

During the call, it was also noted that there is a perception by beneficiaries that the insurance industry is responsible for this issue because they do not fully understand the Medicare coordination of benefits process. One insurance industry association informed CMSCenters for Medicare and Medicaid Services they were recommending that Medicare beneficiaries contact their congressional leadership about specific instances where Medicare has improperly denied coverage.

The following instances of improper Medicare coverage denial were noted during the call:

• Denial of coverage occurring when there is an open payment obligation and ongoing responsibility for medical (ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case)) reported via Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting
• Denial of coverage when the proper ICD-9International Classification of Diseases, 9th Revision codes are reported for the accepted injuries

CMSCenters for Medicare and Medicaid Services confirmed that they are aware of these issues, have received specific examples of inappropriate denial of benefits, and are looking into them. Over the last several months, CMSCenters for Medicare and Medicaid Services stated that they have been focused on outreach and education of contractors and providers to put a stop to this issue. Additionally, CMSCenters for Medicare and Medicaid Services indicated that they have not advised their contractors to deny claims solely because there is an open NGHPNon-Group Health Plan - liablity (including self-insurance), no-fault and workers' compensation record of ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) without examining whether the payment sought was due to a specific illness/injury related to the ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) report.

CMSCenters for Medicare and Medicaid Services offered the following helpful hints to assist in reducing these issues:

• For ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) reports, only submit ICD-9International Classification of Diseases, 9th Revision codes related to the accepted injuries. For example, if ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) has been accepted for a broken arm, only ICD-9International Classification of Diseases, 9th Revision codes related to the arm injury should be reported. ICD-9International Classification of Diseases, 9th Revision codes pertaining to unrelated diagnoses such as hypertension and diabetes should not be included even if they appear on billing forms.
• Assure proper ICD-9International Classification of Diseases, 9th Revision codes are reported. Reporting vague or inaccurate ICD-9International Classification of Diseases, 9th Revision codes can lead to improper denial of coverage.
• Supply as many ICD-9International Classification of Diseases, 9th Revision codes as needed to adequately document the injuries and diagnoses accepted (ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case)) for that claim.
• Responsible Reporting Entities (RREsResponsible Reporting Entities - payers subject to Mandatory Insurer Reporting Requirements mandated by Section 111 of the MMSEA) have the option to make an immediate report of ORMOngoing Responsibility for Medicals (i.e., carrier accepting payment responsiblity for case) termination prior to their next assigned quarterly report submission by contacting the COBCCoordination of Benefits Contractor Call Center at 1-800-999-1118 (specific instructions are in User Guide 3.2- need to provide link).
• The Medicare Secondary Payer Recovery Contractor (MSPRCMedicare Secondary Payer Recovery Contractor - responsible for verification of conditional payments) is not the proper entity to contact regarding denial of Medicare coverage.

If all else fails, the beneficiary is not without recourse. CMSCenters for Medicare and Medicaid Services confirmed that there is an appeals process that the beneficiary can follow if they disagree with the denial. For further information on the Medicare appeals process please see our blog dated August 5, 2011.

While Section 111Section 111 of the Medicare Medicaid and SCHIP Extension Act stating requirements for mandatory insurer reporting reporting was created to assist in the recovery process, it has not been smooth sailing for all parties involved. The industry appears hopeful that CMSCenters for Medicare and Medicaid Services will take heed to the seriousness of this issue and take steps to correct problems on their end. However, in order to fully overcome these issues it will take the effort of not only CMSCenters for Medicare and Medicaid Services, but also everyone involved in this cumbersome and complex process.

Comments (0)

By Settlement Solutions, November 18, 2011 12:50 pm

Prescription drug costs in workers’ compensation claims are rising, making it necessary for claims professionals to carefully evaluate this exposure and mitigate costs when possible.  Staying up to date on current pharmacy trends, including new medications introduced to the market and generic equivalents, is one piece of the equation to mitigating costs.

Every brand medication has a patent life and once the patent expires, generic equivalents will be introduced into the market at a lower cost.  Although there is no set brand versus generic price differential upon generic entry, there is a large cost savings that accompanies the generic release. The gap between brand and generic pricing widens as brand name medications continue to have annual (or quicker) increases to the AWPAverage Wholesale Price (average wholesale price), whereas the generic formulations do not generally experience annual inflation.  Some generic equivalents can launch at reductions of 70% from the brand medication price, which is a significant decrease.  

Recently, there have been several new medications and generic equivalents approved by the FDAU.S. Food and Drug Administration that will have an impact on workers’ compensation claims.  Gralise (Gabapentin) is a new once-a-day dosing of Gabapentin which is FDAU.S. Food and Drug Administration approved for post herpetic neuralgia pain.  It is to be taken once per day with the evening meal, which should lead to better patient compliance along with a better therapeutic outcome.  Gralise has been shown to produce fewer side effects than Lyrica and Neurontin (Gabapentin) and will more than likely gain in popularity among prescribers for its use in treating neuropathy and radiculopathy in chronic pain patients.  At this time, there is no pricing available for Gralise. 

For chronic pain management, a long acting (extended release) pain medication formulation is preferred over its short acting counterpart.   Both Nucynta ERExtended Release (medication) (Tapentadol) and Tramadol ERExtended Release (medication) 300mg- (generic Ultram ERExtended Release (medication) 300mg), which are newly approved medications, fall into this category.  Nucynta ERExtended Release (medication) and Tramadol ERExtended Release (medication) are both pain medications approved by the FDAU.S. Food and Drug Administration for treatment of moderate to severe pain requiring continuous, around the clock analgesia unlike their immediate release formulations, which are taken on an as needed basis.  The average cost of Nucynta ERExtended Release (medication) 50mg twice a day for a month supply is $177.60 while Nucynta 50mg (immediate release) taken once every 4-6 hrs is $277.20; therefore, not only should the extended release formulation provide overall better pain control, but it would also be more cost effective. 

According to PMSI’s Drug Trends Report, Ultram ERExtended Release (medication) is one of the top 20 brand medications prescribed in workers’ compensation.  Ultram ERExtended Release (medication) and its generic Tramadol ERExtended Release (medication) are dosed at once a day.  The average cost of brand Ultram ERExtended Release (medication) 300mg is $279.90 for a one month supply while the generic Tramadol ERExtended Release (medication) 300mg averages $162.30 per month.   Additionally, Tramadol ERExtended Release (medication) is also less expensive than its immediate release formulation, which can be prescribed up to 8 tablets per day, at an average monthly cost of $189.60.

The above noted pricing differences creates an incentive to address the potential use of generic and/or long acting medications with the treating physician when an injured individual is being prescribed the brand or short acting medications, if a cost savings can be realized.  Sleep aids are commonly prescribed medications for workers’ compensation injuries when there are significant pain complaints and insomnia is present.  According to PMSI’s Drug Trends Report, Lunesta was noted to be the second most prescribed medication for insomnia in workers’ compensation.  Generic Lunesta (Eszopiclone) has now been FDAU.S. Food and Drug Administration approved for the treatment of insomnia.  No release date or pricing for the generic has been released by its manufacturer as of today, but the approval of the generic formulation will likely impact medication transaction costs within the workers’ compensation community.

Keeping up to date on new drugs as well as generic formulations as they are approved by the FDAU.S. Food and Drug Administration will help mitigate the rising cost of claims as well as provide for the potential of an overall better therapeutic response for the injured worker.

Comments (0)

By Settlement Solutions, November 15, 2011 2:23 pm

According to an article titled “Government Appealing Medicare Set-Aside Suit” on WorkCompCentral (subscription required), the government plans to appeal the dismissal of U.S. v. Stricker, one of the largest Medicare reimbursement suits ever filed. The government recently filed a motion for reconsideration based upon a theory of “continuing accrual,” that the statute of limitations re-starts each time a class Plaintiff received a settlement payment. The motion for reconsideration was denied on August 12, 2011. For a copy of PMSI’s previous legal bulletins on U.S. v. Stricker please click here.

The WorkCompCentral article states that the Department of Justice has filed a notice of appeal with the U.S. 11th Circuit Court of Appeal, notifying the court that an appeal is forthcoming. Additionally, the article states that since learning of the impending appeal, the attorney defendants have filed a cross-appeal arguing that the three-year statute of limitations applies to them and that the government has until November 22nd to file their appellate brief, which will outline its specific arguments on appeal.  However, an extension of that deadline may be sought.

It will be interesting to see if the government puts forth its theory of “continuing accrual” yet again, and whether the U.S. 11th Circuit Court of Appeal will ultimately agree with the lower court’s decision that the Federal Claims Collection Act (FCCAFederal Claims Collection Act) does apply to Medicare conditional payment matters, and that a six year statute of limitations applies if the underlying claim is a contract, and a three year statute of limitations applies if the underlying claim is a tort.

PMSI will continue to follow this matter and the arguments that are set forth in the government’s appeal. PMSI will also continue to follow and support the SMARTStrengthening Medicare and Repaying Taxpayers Act of 2011 ActStrengthening Medicare and Repaying Taxpayers Act of 2011, which seeks to clarify and set the government’s statute of limitations with regard to conditional payment demands at three years.