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CMS Offers Prescription Drug Set-Aside Guidance PDF  | Print |
Industry News Updates
Written by Doug Shaw, C.P.A.   
Friday, 05 June 2009 09:59
The Centers for Medicare and Medicaid Services (CMS) has released an interesting document to address the many questions that have been raised from their April 3, 2009 memo regarding the pharmacy review of submitted MSAs. In this latest document, CMS provides eight main points of clarification:

  1. Source for Evaluating Drug Component - The Workers’ Compensation Review Contractor (WCRC) will use the Red Book® Drug References to evaluate the sufficiency of the drug component of a Workers Compensation Medicare Set-Asides (WCMSAs).

  2. Documentation - CMS stresses that it is “imperative that submitters furnish accurate, complete, legible, and current medical and prescription records for the last two years…”. They also explain why it is their preference that WCMSAs only be submitted after the claimant has reached maximum medical improvement (MMI) and future drug needs be “reasonable, probable and predictable”.

  3. Tapering of Use – CMS will consider all evidence presented where a treating physician believes that tapering is in the best interest of the claimant.

  4. Expiration of Patent – All evidence submitted will be considered by CMS regarding whether or not a change to a less expensive drug is warranted at the expiration of a patent.

  5. Off-label Use - CMS acknowledges that physicians are free to prescribe an FDA-approved drug for any purpose that is safe and effective, but provides no further guidance as to how they will apply this concept in evaluating WCMSAs except in their conclusion below where they emphasize that they will consider all evidence submitted.

  6. Utilization Review – Utilization reports showing that the claimant should be taking more, different, less frequent or even no drugs will be considered, but more weight will be given to reports of actual drug use from treating physicians.

  7. Brand or Generic - CMS has confirmed their position on brand v. generic drugs. This document again states that where drugs are known to be needed and the submitter has not priced drugs, or the submitter has priced for a generic drug when a generic is not available, CMS will compare the WCMSA proposal to the average wholesale price for brand name drugs. They also state that if drugs are indicated on the proposal but the records do not specify whether the injured party is taking a generic or a brand name drug when both versions exist, CMS will compare the WCMSA proposal to the generic drug where the submitter has proposed a generic drug, and CMS will compare the WCMSA proposal to the brand name drug where the submitter has proposed a brand name drug or has not proposed a drug at all.

  8. Multiple Manufacturers - In the event that the WCMSA submission does not include supporting documentation regarding prices from multiple generic drug manufacturers, CMS will compare generic drugs in the WCMSA proposal and use the lowest priced generic drug as listed in the Red Book Drug References® in accordance with the April 3, 2009 procedure memo.

In conclusion, CMS emphasizes and encourages submitters to present any and all evidence they believe is helpful and CMS will review and consider all documents submitted.

To view this document in its entirety, please click here.
 
CMS Announces Dates and Agenda for Remaining 2009 Town Hall Teleconferences, Releases Companion Document for the HIPAA Guidelines for Electronic Transactions PDF  | Print |
Industry News Updates
Written by Tom Matson   
Monday, 01 June 2009 09:42
On May 26, 2009 the Centers for Medicare and Medicaid Services (CMS) announced the dates and agenda for their remaining 2009 Town Hall Teleconferences. It is important to distinguish that the CMS will conduct a handful of conferences specifically relating to technical questions surrounding the Section 111 data exchange process. There will be a separate group of teleconferences that have been setup to address questions pertaining to Section 111 compliance in general.

Also included in this announcement is a companion document created to supplement the HIPAA guidelines for electronic transactions for Non-GHP Entities. The document provides information on the transactions sets needed to transmit data to, as well as receive data from, the Medicare Coordination of Benefits System.

To view the teleconference dates and agendas, please click here.

To view the companion document for the HIPAA Guidelines for Electronic Transactions, please click here.
 
CMS Releases Reference Guide for Section 111 Registration PDF  | Print |
Industry News Updates
Written by Tom Matson   
Thursday, 21 May 2009 12:50
On May 8, 2009, The Centers for Medicare and Medicaid Services (CMS) released a quick reference guide for Section 111 registration for all Responsible Reporting Entities (RREs). Included within this guide are examples of issues a registrant may encounter when trying to register, such as how to obtain an RRE ID number, and how to register multiple RRE IDs.

Also included with this reference guide are useful web links to Section 111 Mandatory Insurer Reporting pages within the CMS website.

To view this guide, please click here.
 
CMS Updates Section 111 Implementation Timeline PDF  | Print |
Industry News Updates
Written by Tom Matson   
Thursday, 14 May 2009 12:39
On May 11, 2009, The Centers for Medicare and Medicaid Services (CMS) announced several changes relating to Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). These changes include an update to the implementation timeline, as well as updates on reporting thresholds for Total Payment Obligations to Claimants, or TPOCs.

With the release of this memo, the registration period for liability insurance (including self-insurance, no-fault insurance, and workers’ compensation RREs) has been extended. RREs now have from May 1, 2009 through September 30, 2009 to register. Consequently the testing period will now take place from January 1, 2010 through March 31, 2010, with first live files now scheduled to be submitted in the April-June quarter of 2010.

There have also been some changes relating to the TPOCs. The CMS has now determined that the Section 111 reporting will not include the reporting of TPOC amounts with dates prior to January 1, 2010. If a TPOC amount dated on or after January 1, 2010 falls below the threshold amount, the RRE is to add all associated TPOC amounts dated on or after January 1, 2010 in determining if the reporting threshold is met. Any associated TPOC amount occurring prior to January 1, 2010 should not be considered when calculating the TPOC amount for purposes of the reporting threshold. However, The CMS has also stated within this memo that although RREs are not required to report TPOCs where the applicable TPOC date is prior to January 1, 2010, a record will not be rejected based upon a TPOC date before January 1, 2010.

To view this memo in its entirety, please click here.
 
Treasury Predicts Medicare Shortfall By 2017 PDF  | Print |
Industry News Updates
Written by Tom Matson   
Wednesday, 13 May 2009 08:42
On Tuesday May 12, 2009, officials who oversee the Social Security trust fund announced that they now foresee a Medicare shortfall by 2017, two years earlier than was predicted just last year. This same report also predicts a Social Security exhaustion by 2037, which is actually four years earlier than was predicted last year.

Officials went on to state that the main reason for the change in the forecast is the demand for benefits have increased while money paid in has decreased. The increase in benefits has been attributed to growing unemployment and new tax breaks in the economic stimulus package that was passed earlier this year.

The release of this report gives a clear indication as to why the Center for Medicare and Medicaid Services (CMS) will require mandatory insurer reporting. It has become increasingly evident that the stress currently placed on our Social Security and Medicare systems by recent economic developments has brought about the need for this change.

To view this report in its entirety, please click here.
 
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