CMS Physician Follow-Up

CHALLENGE:

Pain management physician dispensed Pennsaid 1.5% (Diclofenac Sodium) for low back pain. Adjuster was not aware that medication had been prescribed as patient was given sample dose followed by paper prescription. Pennsaid did not effectively manage pain so injured worker did not fill the RX. According to CMS guidelines, medications listed as active by the treating physician will be included in the MSA whether or not the drugs are being filled by the patient. Total MSA – $970,355.

solutions-hexSOLUTION:

Tower’s Physician Follow-Up team worked with the assigned nurse to contact the treating physician’s office to communicate that the injured worker was not filling Pennsaid 1.5% noting that the medication did not manage pain effectively. Physician agreed to discontinue Pennsaid 1.5% and replace with oral Diclofenac. A letter was sent to confirm discontinuation.

The letter was executed by the physician with language as follows:

“I discontinued Mr. King’s Pennsaid 1.5%. He was offered Nabumetone, but the patient declined this medication.”

In follow up, both medications were blocked with the PBM to prevent their being reintroduced, the executed physician attestation was appended to the MSA and Pennsaid and Nabumetone were removed from the Rx drug portion of the allocation.

RESULTS: $951,189 IN SAVINGSresults-hex

Once updated to exclude the prescription drugs listed above, total MSA allocation was reduced to $19,166 and submitted to CMS. In its review, CMS accepted Tower’s physician letter as evidence of discontinuation of the medications listed and approved the MSA in full. This resulted in a savings of $951,189.

Tower’s Physician Follow-Up service is provided at no charge when initiated as part of the MSA and CMS submission process.