CMSCenters for Medicare and Medicaid Services has posted an updated contact list for its regional offices that review WCMSAs. The updated contact list can be located here.
Posts tagged: workers’ compensation
Physician dispensing of repackaged drugs continues to be a major contributor to the growing cost of prescription drug treatment within the workers’ compensation industry. In the 2012 Survey of Prescription Drug Management released by CompPharma and authored by Joseph Paduda in January of 2013, it was noted that physician dispensed medications were second only to the use of opioids as the largest driver of workers’ compensation prescription drug costs.
Physician dispensing is not a new practice among physicians. It became popular in the late 19th and early 20th centuries and was first seen in workers’ compensation in California in the middle of the last decade. At that time, physicians began to partner with companies who marketed repackaged drugs for resale as an opportunity for offsetting practice revenue losses due to reimbursement cuts made by government, commercial and workers’ compensation payers.
Repackaged drugs are usually purchased in large quantities from the original manufacturer by companies who then repackage them into smaller quantities for resale. The repackaged drugs are usually sold at a profit by physicians who dispense them to the patient at time of treatment. The FDAU.S. Food and Drug Administration requires the company that is repackaging and relabeling the drugs to assign a new NDC number (different from the original manufacturer’s NDC) and at that time it is common for the company to set a new AWPAverage Wholesale Price (average wholesale price) that is generally higher than the original. This new AWPAverage Wholesale Price is also typically higher than the AWPAverage Wholesale Price utilized by retail and mail order pharmacies and is often not controlled by state fee schedules.
From a workers’ compensation payer’s perspective, arguably there are numerous “Pros” and “Cons” concerning physician dispensing.
*Allows the physician the opportunity to ensure the patient has the medication to begin treatment immediately as it is dispensed at the time of service. Additionally, physician dispensing makes it more convenient for those patients who may have difficulty finding transportation to a retail pharmacy. Those patients that may not otherwise have reliable transportation may postpone filling the medication or never obtain the medication for treatment at all.
* Beneficial for specific medications that require physician monitoring such as those dispensed within a drug rehabilitation program.
*Patient Safety: Since the medication is being dispensed by the physician without the oversight of the pharmacy benefit manager or pharmacist, an important safety check is bypassed. Since the physician must depend on the injured worker to provide the medication history in order to perform drug utilization review, drug therapy problems may go undetected. This leads to possible missed drug interactions, duplicate or excessive drug therapy, as well as other high risk medication concerns.
* Inflated costs: The majority of medications dispensed by physicians are associated with an increased cost per unit because of the creation of a new NDC and AWPAverage Wholesale Price. In many cases this AWPAverage Wholesale Price is much higher (in some cases as much as 400% higher) than the same drug dispensed through the retail or mail order pharmacy setting.
*Administrative inefficiency: It is difficult for bill review systems to identify physician dispensed drugs as they are often simply included in the physician’s treatment bill and the reviewer is unable to separate the cost of treatment from that for drugs. As these transactions are often billed on paper, this drives additional cost for payers compared to PBMPharmacy Benefit Management-billed transactions that tend to be billed electronically. This also makes it very difficult for the payer to build a complete data picture of the magnitude and amount of physician dispensed drugs.
As the practice of physician dispensing continues to gain in popularity, it will remain a concern for payers of worker’s compensation claims. Due to the financial benefits as well as aggressive marketing by the repackaging companies, it is estimated that the percentage of physicians dispensing drugs is growing well over 10% per year. In response to this, many, but not all of the states, have begun to change regulations monitoring physician dispensing in an attempt to help control the inflated cost due to this type of dispensing.
In order to control rising costs, it is important that the workers’ compensation industry work with state legislators to provide insight into this issue. It is equally important for the industry to remain informed on how physician dispensing is being handled by each individual state. Payers should also discuss with their PBMsPharmacy Benefit Managers their approach to controlling physician dispensing and to ensure sure that it is being actively managed and monitored.
At last, one of the components of the SMARTStrengthening Medicare and Repaying Taxpayers Act of 2011 ActStrengthening Medicare and Repaying Taxpayers Act of 2011 is set to take effect on July 10, 2013. The SMARTStrengthening Medicare and Repaying Taxpayers Act of 2011 ActStrengthening Medicare and Repaying Taxpayers Act of 2011, also known as H.R. 1845, provides that: six months after enactment (signed by President Obama on January 10, 2013), an action for recovery of conditional payments cannot be brought unless it is less than 3 years after the date of the receipt of notice of a settlement, judgment, award or other payment by CMSCenters for Medicare and Medicaid Services/DHHSDepartment of Health and Human Services.
So what does this mean? This means that recovery of conditional payments is limited to three (3) years from the date of notice to CMSCenters for Medicare and Medicaid Services on any cases that settle after July 10th of this year, as long as CMSCenters for Medicare and Medicaid Services is notified of the settlement, judgment, or award. Three years after a case settles and notice is provided to CMSCenters for Medicare and Medicaid Services, you can finally rest assured that CMSCenters for Medicare and Medicaid Services won’t be looking for additional monies from that workers’ compensation, liability or no-fault case you settled.
Until the SMARTStrengthening Medicare and Repaying Taxpayers Act of 2011 ActStrengthening Medicare and Repaying Taxpayers Act of 2011, there was no clear statute of limitations for conditional payment recovery; although cases such as U.S. v. Stricker attempted to interpret it via case law. A clear statute of limitations through legislative reform to the MSPMedicare Secondary Payer Act Act was needed as any case law which attempted to interpret what the Statute of Limitations would seemingly only apply to that jurisdiction where the case was decided. This could potentially create a lack of consensus among jurisdictions on a Federal issue which really should be determined through the legislative or executive branch rather than the judicial. The SMARTStrengthening Medicare and Repaying Taxpayers Act of 2011 ActStrengthening Medicare and Repaying Taxpayers Act of 2011 accomplished this.
One great aspect of this new statute of limitations is that it is a self-enacting provision of the SMARTStrengthening Medicare and Repaying Taxpayers Act of 2011 ActStrengthening Medicare and Repaying Taxpayers Act of 2011. Unlike some of the other components of the SMARTStrengthening Medicare and Repaying Taxpayers Act of 2011 ActStrengthening Medicare and Repaying Taxpayers Act of 2011, CMSCenters for Medicare and Medicaid Services does not need to promulgate rules or post a proposed rulemaking in the Federal Register for this to begin. Therefore, PMSI highly encourages payers to take note of this new statute of limitations and ensure that CMSCenters for Medicare and Medicaid Services is noticed on the appropriate settlements so that payers can take advantage of the statute of limitations which will be effective on July 10, 2013 as a result of the SMARTStrengthening Medicare and Repaying Taxpayers Act of 2011 ActStrengthening Medicare and Repaying Taxpayers Act of 2011.
CMSCenters for Medicare and Medicaid Services has issued an alert notifying the industry of a reorganization of the MSPMedicare Secondary Payer Act sections of its website. There appears to be no substantive changes to the MSPMedicare Secondary Payer Act program, but rather what appears to be an ongoing reorganization and consolidation of information.
Below is the text of the alert:
The Coordination of Benefits and Medicare Secondary Payer Recovery sections on the Medicare tab of the CMSCenters for Medicare and Medicaid Services.Gov Web Site have been redesigned and restructured. As part of this restructuring, all pertinent information from the MSPRCMedicare Secondary Payer Recovery Contractor - responsible for verification of conditional payments.info web site has been incorporated into this new design and web page links have changed. Please visit the Coordination of Benefits & Recovery section of CMSCenters for Medicare and Medicaid Services.gov to see our new web pages.
CMSCenters for Medicare and Medicaid Services provides the ability for you to be automatically notified when changes are made to the Coordination of Benefits & Recovery Overview web pages. If you have not already signed up for these notifications, please click the Subscription Sign-up Notification link found in the Related Links section of the web pages. When new information regarding Coordination of Benefits & Recovery are available, you will be notified. These announcements will also be posted to the What’s New page of the corresponding web pages.
The following short-cuts have also been created for each of the new web pages:
Coordination of Benefits & Recovery Overview: http://go.cmsCenters for Medicare and Medicaid Services.gov/cobro
Attorney Services: http://go.cmsCenters for Medicare and Medicaid Services.gov/attorney
Beneficiary Services: http://go.cmsCenters for Medicare and Medicaid Services.gov/bene
COBA Trading Partners: http://go.cmsCenters for Medicare and Medicaid Services.gov/cobatp
Employer Services: http://go.cmsCenters for Medicare and Medicaid Services.gov/employer
Insurer Services: http://go.cmsCenters for Medicare and Medicaid Services.gov/insurer
Prescription Drug Assistance Programs: http://go.cmsCenters for Medicare and Medicaid Services.gov/pdap
Provider Services: http://go.cmsCenters for Medicare and Medicaid Services.gov/provider
Mandatory Insurer Reporting For Group Health Plans: http://go.cmsCenters for Medicare and Medicaid Services.gov/mirghp
Mandatory Insurer Reporting For Non Group Health Plan: http://go.cmsCenters for Medicare and Medicaid Services.gov/mirnghp
Workers’ Compensation Medicare Set-Aside Arrangements: http://go.cmsCenters for Medicare and Medicaid Services.gov/wcmsaWorkers' Compensation Medicare Set-Aside