Tag Archives: CMS

Prescription drug updates may positively affect Medicare Set Aside

As part of our best business practices, we continually monitor RED BOOK®Average Wholesale Price (AWP) of the most common medications present in Workers’ Compensation Medicare Set-Aside (WCMSA) arrangements. This practice assists in identifying price changes positively affecting WCMSAs.

The month of February brought price drops of the following medications:

  • buprenorphine/naloxone (Suboxone®) commonly prescribed for opioid dependence
  • diclofenac (Voltaren®) in multiple strengths used to treat pain
  • methadone (Dolophine®) commonly prescribed for detoxification or pain management
  • bupropion (Wellbutrin®) in multiple strengths prescribed for depression
  • clonazepam (Klonopin®) used for anxiety or panic disorders
  • quetiapine (Seroquel®) commonly used to treat bipolar disorder, depression or schizophrenia
  • tramadol (Ultram®) used to treat pain

The products in the following table have a reduced AWP, confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Product Name

NDC Code

Dosage Form

Strength

AWP Unit Price Reduction

Bupropion Hydrochloride

00781-5528-31

TER

150 mg

$3.92

Bupropion Hydrochloride

00781-5529-31

TER

300 mg

$2.24

Diclofenac Sodium

61145-0102-12

ECT

75 mg

$0.51

Buprenorphine Hydrochloride/Naloxone Hydrochloride

00406-8020-03

SL TAB

8/2 mg

$0.34

Clonazepam

00781-8018-05

TAB

0.5 mg

$0.11

Diclofenac Sodium

61145-0101-18

ECT

50 mg

$0.10

Quetiapine Fumarate

00904-6639-61

TAB

50 mg

$0.09

Tramadol Hydrochloride

68094-0017-61

TAB

50 mg

$0.06

Methadone Hydrochloride

66689-0898-40

TBS

40 mg

$0.04

Please note that RED BOOK AWP is subject to change and this pricing is subject to an increase or decrease in the future.

CMS uses the lowest AWP when reviewing a WCMSA. The lower price of these medications will immediately affect the prescription costs for WCMSAs (both present as well as prior WCMSA’s that have not settled and there is no CMS determination issued). We will contact our clients in reference to previously completed WCMSA’s where these medications have been prescribed. It is our recommendation that carriers, TPAs and claim handlers review cases to determine the benefit from decreased cost of these medications.

Optum will continue to keep the industry informed of changes in AWP pricing, in addition to when generic equivalents enter the market.

Prescription Medication Updates That May Affect Your Medicare Set-Aside

We continually monitor pricing of the most common medications seen in Workers’ Compensation Medicare Set-Aides (WCMSAs) in order to identify pricing changes affecting MSAs positively. The month of December brought a price drop for gabapentin 800mg tablets commonly used to treat neuropathic pain.

Below is the product confirmed to have a reduced AWP and confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Product name NDC Code Dosage form Strength AWP unit price reduction
Gabapentin 00904-6586-61 TAB 800 mg $2.16

Please note RED BOOK® AWP (Average wholesale price) is subject to change and this pricing is subject to an increase or decrease in the future.  

CMS will utilize the lowest AWP published by RED BOOK when reviewing a WCMSA, therefore the lower pricing of these medications will immediately impact the prescription costs for WCMSAs (both present as well as prior WCMSAs that have not settled and there is no CMS determination issued) where these drugs are prescribed.

It is our recommendation carriers, TPAs and claim handlers review cases where the above noted medication is prescribed to determine the benefit from decreased cost. We will proactively reach out to our clients in reference to previously completed WCMSA’s where this medication was prescribed and  continue to monitor future portal changes and generic equivalents introduced to the market in order to keep the industry informed.

CMS Releases NGHP Section 111 User Guide v5.2

CMS has released an updated NGHP User Guide, version number 5.2. The update clarifies MIR Section 111 reporting thresholds initially addressed in a published alert by CMS Financial Services Group posted to the Non-Group Health Plan Recovery site on November 15, 2016 entitled “2017 Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards or Other Payments”. The changes to thresholds are summarized below.

For Section 111 reporting, the Centers for Medicare & Medicaid Services (CMS) has changed the minimum reportable Total Payment Obligation to the Claimant (TPOC) amounts for liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claims.

  • Liability is changing from $1000 to $750 for TPOC Dates of 1/1/2017 and subsequent.
  • No-Fault is changing from $0 to $750 for TPOC Dates of 10/1/2016 and subsequent.
  • Workers’ Compensation (WC) is changing from $300 to $750 for TPOC Dates of 10/1/2016 and subsequent.

TPOC amounts exceeding these thresholds must be reported. However, TPOC amounts less than the specified threshold may be reported and will be accepted.

The logic for the CJ07 error has been changed such that a TPOC of any amount will be accepted for all types of TPOCs, including liability TPOCs. The CJ07 error will continue to be returned for a liability, workers’ compensation, or no-fault claim report where the ORM Indicator is set to “N” and the cumulative TPOC amount is zero.

We are able to provide a consolidated PDF file of all the updated chapters upon request. Please contact us at JustRegister@optum.com if you would like to receive this consolidated, searchable file. For more information, please email JustRegister@optum.com.

Bid for WCRC with LMSA Capabilities Delayed by CMS

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) solicited bids in an RFP for a Workers’ Compensation Review Contractor (WCRC) to review workers’ compensation Medicare Set Aside (WCMSA) proposals, which potentially include liability Medicare Set Asides (LMSAs). The bid was to be released on September 22, 2016, but has been delayed. When this deadline passed without the release of the solicitation, we were notified of the delay. CMS has postponed the award date and now anticipates releasing the bid sometime during the first quarter of fiscal year 2017, pending availability of funds. However, the dates are subject to change.

Although not certain, it is anticipated that guidelines for review of LMSAs or modifications to current WCMSA review thresholds will be shared prior to release of the solicitation. While we remain alert to potential changes in the future, our present services continue without change. Upon release of the bid and identification of WCMSA contractor, there are a few potential areas of consideration:

  • A new WCMSA contractor may delay MSA approval times
  • A new WCMSA contractor may result in inconsistencies in acceptance of what is allocated
  • Either the same or a new WCMSA contractor who is trained for LMSAs may result in inconsistencies and delays
  • The same WCMSA contractor may add LMSA reviewers for new guidelines which may result in inconsistencies and delays

If LMSAs are included in the responsibilities of the WCRC, guidelines for LMSAs are expected to be released. Guidelines will review threshold amounts and share an apportioning formula for use for both the extent of liability and the extent of injuries based upon a ceiling of policy limits. They are also expected to include total settlement amount, judgment rendered or arbitration amount awarded. In the meantime, efforts to equitably influence the LMSA guidelines are anticipated from CMS.

We expect further communication from the CMS in the coming months. Our teams remain engaged with these changes and will share information with you as it becomes available.