CMS Re-Review

CHALLENGE:

CMS countered higher to include Gabapentin 600 mg tablets (AWP-$2.28) increasing the CMS approved MSA amount to $98,054. Physician had increased prescribed strength from 300mg to 600mg. However, injured worker had not filled 600 mg prescription. Rx history showed consistent fills of Gabapentin 300mg capsure(AWP -.03).

solutions-hexSOLUTION:

Tower’s Physician Follow-Up team prepared a letter for submission to the treating physician to allow for continued fills of Gabapentin 300 mg capsules. As required in Montana, notice was given to the injured worker and his counsel prior to initiating contact with the phsyician.

The letter was submitted to the physician’s office via fax and was placed on physician’s letterhead and executed by the physician with language as follows:

“The above captioned patient is under my care for treatment of chronic back pain and neuropathic pain. He will be prescribed Gabapentin 300 mg capsules taking 2 capsules three (3) times / day to help him manage his pain.”

The executed physician letter was submitted to CMS for Re-Review.

RESULTS: 60% REDUCTION OF MSAresults-hex

CMS accepted Tower’s physician letter and reduced its CMS approved MSA amount from $98,054 to $33,319, resulting in a savings of $64,735. While CMS stipulates in its guidelines that documentation obtained post CMS submission will not be accepted, Tower’s use of the rationale that the injured worker had not filled the 600 mg strength was effective to obtain a positive CMS Re-Review outcome.

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