National Alliance for Medicare Set-Aside Professionals (NAMSAP) Names Tower MSA CEO Rita Wilson To Board

January 28, 2016

Elmhurst, IL, January 26, 2016: On Thursday, January 21, 2015, the Board of Directors of the National Alliance for Medicare Set-Aside Professionals elected the following officers for the 2016 year:

 

    • Vice President: Shawn Deane, JD, MEd, MSCC, CMSP – Assistant Vice President of Product Development of ISO Claims Partners

 

 

    • Secretary: Christine Melancon, RN, CCM, MSCC, CNLCP, CMSP – Vice President of Operations for EZ-MSA Services

 

“I am honored to have been selected by my fellow board members to represent them and our association as president,” said Patureau. “I look forward to working with our team of board members, committee chairs, management staff and all NAMSAP members to continue to strengthen our mission as the leading advocate for an efficient and effective Medicare Secondary Payer (MSP) compliance system. Following the steps of previous leaders and that of my predecessor Kim Wiswell, I am committed to promoting and growing our association, providing our members with the educational and networking opportunities they need for professional development as well as bolstering NAMSAP’s strategic goals”.

NAMSAP would like to thank Benjamin M. Basista, Esq., member of the Board of Directors since 2010 and most recently Vice President for his service to the organization. Basista is a shareholder with Dickie, McCamey & Chilcote, PC and Co-Chair of the firm’s Medicare Compliance Group, in which he concentrates his practice.

Immediate Past President Kimberly A. Wiswell, Director of Operations for MEDVAL, had this to say: “NAMSAP is a better organization thanks to Ben’s time, talent and expertise. Beyond his work on the legislative and bylaw side of the organization, Ben served as the liaison to the Membership Committee and was a consistent presence at all of our events providing his ideas, input, and enthusiasm. On behalf of the NAMSAP board we express our sincere appreciation for his service and wish him the very best in the future.”

In addition to electing officers, the NAMSAP board appointed Rita M. Wilson, CEO of Tower MSA Partners to the vacancy created by Basista’s departure. Ms. Wilson oversees all business development, sales, marketing and operational activities, IT systems development, and identifies new product offerings in support of MSP compliance. Within NAMSAP, she is Chair of the Communications Committee and a member of both the Data and Development Committee (DDC) and Evidence Based Medicine (EBM) Committee.

“Rita’s knowledge and experience in the industry as well as her commitment to NAMSAP make her an excellent addition to the overall team” said Patureau.

The National Alliance of Medicare Set-Aside Professionals (NAMSAP) is the only non-profit association exclusively addressing the issues and challenges of the Medicare Secondary Payer Statute and its impact on workers’ compensation and liability settlements. Through the voluntary efforts of our members, NAMSAP is a forum for the exchange of ideas and is a leading resource for information and news in this constantly evolving area of practice. The collective knowledge of our members and NAMSAP’s resources will provide attorneys, nurses, settlement planners, claims professionals, and others with the ingredients essential to their success.

Click here to download this press release.

National Alliance for Medicare Set-Aside Professionals (NAMSAP) Names Tower MSA CEO Rita Wilson To Board

Elmhurst, IL, January 26, 2016: On Thursday, January 21, 2015, the Board of Directors of the National Alliance for Medicare Set-Aside Professionals elected the following officers for the 2016 year:

 

    • Vice President: Shawn Deane, JD, MEd, MSCC, CMSP – Assistant Vice President of Product Development of ISO Claims Partners

 

 

    • Secretary: Christine Melancon, RN, CCM, MSCC, CNLCP, CMSP – Vice President of Operations for EZ-MSA Services

 

“I am honored to have been selected by my fellow board members to represent them and our association as president,” said Patureau. “I look forward to working with our team of board members, committee chairs, management staff and all NAMSAP members to continue to strengthen our mission as the leading advocate for an efficient and effective Medicare Secondary Payer (MSP) compliance system. Following the steps of previous leaders and that of my predecessor Kim Wiswell, I am committed to promoting and growing our association, providing our members with the educational and networking opportunities they need for professional development as well as bolstering NAMSAP’s strategic goals”.

NAMSAP would like to thank Benjamin M. Basista, Esq., member of the Board of Directors since 2010 and most recently Vice President for his service to the organization. Basista is a shareholder with Dickie, McCamey & Chilcote, PC and Co-Chair of the firm’s Medicare Compliance Group, in which he concentrates his practice.

Immediate Past President Kimberly A. Wiswell, Director of Operations for MEDVAL, had this to say: “NAMSAP is a better organization thanks to Ben’s time, talent and expertise. Beyond his work on the legislative and bylaw side of the organization, Ben served as the liaison to the Membership Committee and was a consistent presence at all of our events providing his ideas, input, and enthusiasm. On behalf of the NAMSAP board we express our sincere appreciation for his service and wish him the very best in the future.”

In addition to electing officers, the NAMSAP board appointed Rita M. Wilson, CEO of Tower MSA Partners to the vacancy created by Basista’s departure. Ms. Wilson oversees all business development, sales, marketing and operational activities, IT systems development, and identifies new product offerings in support of MSP compliance. Within NAMSAP, she is Chair of the Communications Committee and a member of both the Data and Development Committee (DDC) and Evidence Based Medicine (EBM) Committee.

“Rita’s knowledge and experience in the industry as well as her commitment to NAMSAP make her an excellent addition to the overall team” said Patureau.

The National Alliance of Medicare Set-Aside Professionals (NAMSAP) is the only non-profit association exclusively addressing the issues and challenges of the Medicare Secondary Payer Statute and its impact on workers’ compensation and liability settlements. Through the voluntary efforts of our members, NAMSAP is a forum for the exchange of ideas and is a leading resource for information and news in this constantly evolving area of practice. The collective knowledge of our members and NAMSAP’s resources will provide attorneys, nurses, settlement planners, claims professionals, and others with the ingredients essential to their success.

Growing Press Surrounds Tower MSA’s Groundbreaking MSP Automation Suite

January 25, 2016

An article today posted by Yahoo! Finance discusses the new MSP Automation Suite by Tower MSA. The article cited the groundbreaking and sophisticated technology developed by Tower MSA that drives the MSP process.

Describing the MSP Automation Suite:

“The sophisticated technology drives all the processes Tower has perfected to proactively manage Section 111 Mandatory Insurer Reporting, the recently implemented Conditional Payment Notice process, and to stage workers’ compensation claims for Medicare Set-Asides and closure.”

Our CEO Rita Wilson offered many insights about the new MSP Automation Suite:

“Essentially, it automates our best practices for Medicare Secondary Payer compliance, claims optimization and MSA preparation.”

“Our Pre-MSA Triage identifies barriers to settlement and recommends claim-specific interventions, like physician peer review and clinical oversight, to remove those barriers long before preparing an MSA.”

“Clients don’t need to manually diary activities or call to check on things.”

“The system shows exactly when a phone call was made, and follow-up is due.”

“Automation frees claims professionals to address issues that require a human touch.”

The article went on to say:

“The MSP Automation Suite can track a claim from Medicare beneficiary identification through final settlement. It records every claim activity performed by Tower or its network of practicing physicians and pharmacists and provides clients with 24/7, end-to-end visibility into claims. The system prompts for missing data, conditional payment searches, and medical/pharmaceutical interventions and sends electronic updates to clients at appropriate data points.”

If you would like to read the full article, it is available here on Yahoo! Finance.

Growing Press Surrounds Tower MSA’s Groundbreaking MSP Automation Suite

An article today posted by Yahoo! Finance discusses the new MSP Automation Suite by Tower MSA. The article cited the groundbreaking and sophisticated technology developed by Tower MSA that drives the MSP process.
MSP Automation Suite

Describing the MSP Automation Suite:

“The sophisticated technology drives all the processes Tower has perfected to proactively manage Section 111 Mandatory Insurer Reporting, the recently implemented Conditional Payment Notice process, and to stage workers’ compensation claims for Medicare Set-Asides and closure.”

Our CEO Rita Wilson offered many insights about the new MSP Automation Suite:

“Essentially, it automates our best practices for Medicare Secondary Payer compliance, claims optimization and MSA preparation.”

“Our Pre-MSA Triage identifies barriers to settlement and recommends claim-specific interventions, like physician peer review and clinical oversight, to remove those barriers long before preparing an MSA.”

“Clients don’t need to manually diary activities or call to check on things.”

“The system shows exactly when a phone call was made, and follow-up is due.”

“Automation frees claims professionals to address issues that require a human touch.”

The article went on to say:

“The MSP Automation Suite can track a claim from Medicare beneficiary identification through final settlement. It records every claim activity performed by Tower or its network of practicing physicians and pharmacists and provides clients with 24/7, end-to-end visibility into claims. The system prompts for missing data, conditional payment searches, and medical/pharmaceutical interventions and sends electronic updates to clients at appropriate data points.”

If you would like to read the full article, it is available here on Yahoo! Finance.

Tower MSA Feaured On Yahoo! Finance

January 21, 2016

An excellent article on Yahoo! Finance today features our Tower MSA Pre-MSA Triage Program.

Pre-MSA Triage
“Workers’ compensation payers using Tower MSA Partners’ Pre-MSA Triage have seen their Medicare Set-Aside allocations dramatically reduced.”

The article went on to say:

“Tower’s Pre-MSA Triage analyzes medical and pharmacy records, identifies unnecessary, inappropriate, cost-driving treatment and recommends interventions to improve patient and financial outcomes. The service ensures that MSAs include only accurate and appropriate medical and pharmaceutical allocations.”

The article also cited case studies:

“In another case, more than $210,000 of a $239,006 projected MSA was due to medication costs, including prescriptions no longer being filled. “We believed the medications were no longer necessary and should be discontinued,” Wilson said, “but without proper documentation and the correct MSA language, they would have been included in future treatment and costs.”

The full article on Yahoo! Finance is available here.

Pre-MSA Triage Works!

pills and money

Inappropriate and/or unnecessary prescription drugs, along with recommended medical procedures that are recommended, but never performed, are all too common in workers’ compensation claims. Yet they are often overlooked when moving a claim to settlement. But a new tool is helping payers identify and address obstacles, saving millions of dollars in MSA and settlement costs. Several recent cases bear out the program’s success.

Tower MSA Partners developed this unique service to ensure MSAs include only accurate and appropriate medical and pharmaceutical treatment. The Pre-MSA Triage allows payers to stage claims for optimal outcomes by providing a snapshot of MSA exposure before the MSA. By following our recommended interventions, clients are achieving CMS approval of reduced MSAs, with reductions of more than 50% in many cases.

How it works

Tower analyzes 6 months of medical records to identify care and cost issues, including the projected MSA cost of a claim based on the current medical and pharmacy treatment regimen. The review also provides a snapshot view of the MSA exposure in a non-discoverable (not an MSA) format, and offers an overview of inappropriate, unnecessary treatment and cost drivers that may impact MSA and settlement. For example, the review may uncover denied injuries and/or body parts, recommended surgical procedures that were never pursued, spinal cord stimulators that were recommended but never evaluated, gaps in treatment dates, unrelated medications, and off-label drug usage.

We then recommend various interventions, such as physician peer review, clinical oversight and conditional payment searches/negotiations to effect improved outcomes and savings in the overall claim costs, frequently as much as 50 percent!

Example Case Study

Tower’s Pre-MSA Triage projected the MSA cost for a 46-year-old male at $1,300,000. More than $1,000,000 of the total projection was due to extended prescribing of both long and short acting opioids. Tower recommended a Physician Peer Review followed by direct dialogue with the treating physician. Agreement to wean was obtained in writing and Tower initiated its clinical nurse oversight service to track progress.

Through Tower’s MSP Automation Suite, developed and maintained internally, we were able to drive the weaning process with the physician through tracked monthly calls, and to guide the adjuster as to when discontinued medications should be blocked by the client’s PBM.

Upon finalization of the weaning process, Tower worked with defense to obtain the necessary written language from the treating physician to confirm discontinuation and remove past medications. The final MSA was submitted and approved by CMS for $210,641 – a savings of more than $1,000,000 from the original estimate!

Conclusion

The example provided here is one of many success stories we are seeing, and through our MSP Automation Suite, we’ve been able to manage the process from triage through final CMS submission and approval in a secure, digital environment. Whether handled internally by our team of nurses or through a formal intervention and peer dialogue by one of our physicians, our system drives every step in the process.

Many companies can identify problems, and some even make recommendations. At Tower, we believe the key to successful MSA outcomes is a proactive approach to identify, intervene and remain involved through closure.

CMS Announces Portal Functionality for Final Conditional Payment Process

News

In its ‘What’s New’ section, CMS announced on November 9, 2015 that as part of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act), the MSPRP will be modified to include Final Conditional Payment (CP) process functionality by January 1, 2016. This new functionality will permit authorized MSPRP users to notify CMS that a recovery case is 120 days (or less) from an anticipated settlement and request that the recovery case be a part of the Final CP process.

When the Final CP process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute. Once all disputes have been resolved, and the case is within 3 days of settling, the beneficiary or their authorized representative will be able to request a Final Conditional Payment Amount on the MSPRP. Once calculated, this amount will remain the Final Conditional Payment Amount as long as:

The case is settled within 3 calendar days of requesting the Final Conditional Payment Amount, and
Settlement information is submitted through the MSPRP within 30 calendar days of requesting the Final Conditional Payment Amount.

How the NGHP recovery process works today

To understand the value of this announcement to simplify the final demand process, we need to revisit the recent changes in NGHP recovery and the new role of the Commercial Repayment Center (CRC).

Effective October 5, 2015, the CRC assumed responsibility for pursuing recovery directly from the applicable plan. Any recoveries initiated by the Benefits Coordination & Recovery Center (BCRC) prior to the October 2015 transition will continue to be the responsibility of the BCRC. The typical recovery case, where Medicare is pursuing recovery directly from the applicable plan, now involves the following steps:

1. Medicare is notified that the applicable plan has primary responsibility

Medicare may learn of other insurance through a Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 report or beneficiary self-report. If Medicare is notified that the applicable plan is primary to Medicare, Medicare records are updated with this information.

2. CRC searches Medicare records for claims paid by Medicare

The CRC begins identifying claims that Medicare has paid that are related to the case, based upon details about the type of incident, illness, or injury alleged. The claims search will include claims from the date of incident to the current date. If a termination date for Ongoing Responsibility for Medicals (ORM) has already been reported, the CRC will collect claims through and including the termination date.

3. CRC issues Conditional Payment Notice (CPN) to the applicable plan

The CPN provides conditional payment information. It advises the applicable plan that certain actions must be taken within 30 days of the date on the CPN or the CRC will automatically issue a demand letter. This notice includes a claims listing of all items and services that Medicare has paid that are related to the case. It also explains how to dispute any items and services that are not related to the case. A courtesy copy of the CPN is sent to the beneficiary and beneficiary’s attorney or other representative. The applicable plan’s recovery agent will also receive a copy of the CPN if the recovery agent’s information was submitted on the applicable plan’s MMSEA Section 111 report or the applicable plan has otherwise appointed a recovery agent by submitting a written authorization to the CRC.

Note: If a beneficiary or his or her attorney or other representative reports a no-fault insurance or workers’ compensation situation before the applicable plan submits a Section 111 report, the applicable plan will receive a Conditional Payment Letter (CPL). The CPL provides the same information as a CPN, but there is no specified response timeframe. When this occurs, the applicable plan is encouraged to respond to the CPL to notify the CRC if it does not have ORM and will not be reporting ORM through Section 111 reporting or if the applicable plan would like to dispute relatedness.

4. Applicable plan submits a dispute

The applicable plan has 30 days to challenge the claims included in the CPN. The applicable plan may contact the CRC or use the Medicare Secondary Payer Recovery Portal (MSPRP) to respond to the CPN.

5. CRC issues recovery demand letter advising plan of monies owed to Medicare

The demand letter advises the applicable plan of the amount of money owed to the Medicare program and requests reimbursement within 60 days of the date of the letter. A courtesy copy of the demand letter is sent to the applicable plan’s recovery agent, the beneficiary and the beneficiary’s attorney or other representative. The demand letter includes the following:

The beneficiary’s name and Medicare Health Insurance Claim Number (HICN);
Date of accident/incident;
A claims listing of all related claims paid by Medicare for which Medicare is seeking reimbursement from the applicable plan; and
The total demand amount (amount of money owed) and information on administrative appeal rights.
If the CRC agrees with disputes submitted timely, unrelated claims will be removed from the case before the demand letter is issued. Please note that the demand letter may include related claims that Medicare paid after the CPN was issued. Relatedness disputes on all claims included in the demand letter may be addressed by submitting an appeal.

6. Applicable plan submits an appeal

An applicable plan has 120 days from the date the applicable plan receives the demand letter to file an appeal. Receipt is presumed to be within 5 calendar days absent evidence to the contrary.

7. Applicable plan submits payment

If the CRC receives payment in full, it will issue a letter stating that the specified debt has been resolved. The letter will also note that new cases may be created if the applicable plan maintains ORM or the CRC receives information on additional items or services paid by Medicare during the period of ORM.

Facilitating timely and more accurate final demands

Because the CRC retains the right to create new cases as long as the applicable plan maintains ORM, timely notification of a final settlement is extremely critical to terminate the recovery efforts of the CRC. We applaud the addition of CP process functionality to the MSPRP as a segue to real time information and data exchange, and a more predictable outcome.

With more timely submissions and a published timeline for the final demand, this new extension of the SMART Act will facilitate better accuracy, a better path to closure and fewer last minute surprises…. all good things for those who represent the settlement interests workers’ compensation and liability carriers.

Closed Formularies Hold Promise for Workers’ Compensation Pharmacy Management

pills and money

With the signing of A.B. 1124 by Governor Jerry Brown October, California has now joined a handful of states that have adopted closed pharmaceutical formularies in their workers’ compensation systems. While many details have yet to be worked out, the decision comes as good news for injured workers and payers alike.

Closed formularies essentially use evidence-based medicine to identity the prescription drugs that should be allowed for certain injuries. All other medications must go through a preauthorization process. The idea is to ensure the injured worker gets the right medication at the right time for the right reasons – AND to reduce unnecessary pharmacy costs.

Implemented appropriately, a formulary can result in better outcomes and lower costs. In fact, a study last year suggested California’s workers’ compensation system could save between $124 million and $420 million annually by adopting a formulary similar to that in effect elsewhere.

In addition to the states that have already implemented closed formularies or are in the process of doing so, several others are considering the idea. The result could be better efficiencies and significant savings for Tower MSA Partners’ clients in managing workers’ compensation claims even before the Medicare Set Aside review and triage process.

The specifics

Under A.B. 1124, the administrative director of California’s Division of Workers’ Compensation must create a formulary by July 1, 2017 for medications prescribed to injured workers. Between now and then, California regulators must determine a program that best addresses the needs of California’s injured workers.

Four states – Ohio, Oklahoma, Texas and Washington have implemented closed drug formularies. Arizona, Arkansas, California, Louisiana, Maine, Michigan, Montana, Nebraska, North Carolina and Tennessee are among the other states considering the formularies or in the midst of developing them.

There are several different types of formularies in effect. Washington, which adopted the first such formulary in 2004, has a more restrictive program than those in some other states. Texas, on the other hand includes more therapeutic groups and more choices within each group.

Regardless of the type of formulary, the states have touted successes. Texas, Washington and Ohio have all reported lower costs.

Texas, which implemented its closed formulary for new injuries in September 2011 and for all injuries in September 2013, also reported the number of injured employees receiving ‘N’ drugs – those requiring preauthorization – fell 65% and costs dropped 83% for new claims for injuries suffered on or after Sept. 1, 2011. Also important, the formulary has led to a significant reduction in the number of injured workers taking opioids on a long-term basis.

The Ohio Bureau of Workers’ Compensation likewise reported significant utilization and cost declines, including a 74% drop in skeletal muscle relaxants, a 25% decline in narcotics and a total drug cost drop of 16%, for a total of $20.7 million, in fiscal year 2014 compared with fiscal year 2011.

Many decisions must be made before California’s formulary takes effect and a variety of issues must be addressed. For example, the pre-approval process for drugs not allowed, decisions about the strategy for long-time opioid users, and considerations of compound medications must be determined.

Fortunately, a team of workers’ compensation stakeholders involved in helping to craft the legislation ensured some important provisions were included. The law requires the California Division of Workers’ Compensation to update the formulary at least quarterly, establish an independent pharmacy and therapeutics committee, accept public comment and publish two interim status reports

Supporters are confident when all is said and done, California’s formulary will provide effective treatment for injured workers, reduce delays and medical disputes, and reduce costs.

How closed formularies impact claims and MSAs

Closed formularies can serve as a gatekeeper in preventing troublesome medications being prescribed to injured workers. Medical providers in states with closed formularies tend to change their behavior and prescribe more clinically appropriate medications and treatments rather than unnecessary opioids and other drugs that require preauthorization.

While providers need approval to be reimbursed for medications not automatically allowed, supporters say closed formularies do not seek to prevent injured workers from having access to medications that are truly beneficial to them.

Workers’ compensation payers can also look for less adversarial relationships with providers, since there will be fewer questionable medications prescribed for the injured worker. Drugs that are not appropriate for first line therapy are generally those that are not allowed without prior authorization, under the closed formularies.

Many steps must be taken before California’s closed drug formulary will take effect and the devil is surely in the details. However, the fact that the nation’s largest workers’ compensation market is going in this direction is good news indeed!

Tower MSA Partners’ Kristine Wilson Will Participate on the MSP/MSA Compliance Panel at California Workers’ Compensation & Risk Conference

Kristine Wilson

Wilson will discuss CMS changes to conditional payments and other compliance issues

DELRAY BEACH, Fla.–(BUSINESS WIRE)–Kristine Wilson, COO and senior legal counsel for Tower MSA Partners, will speak at the California Workers’ Compensation & Risk Conference. Tower MSA Partners provides Medicare Set-Aside compliance services nationally and specializes in reducing medical and pharmacy costs on claims prior to settlement.

Wilson will participate on the “MSP/MSA Compliance Open Mic” panel. Topics include whether or not to submit an MSA to the Centers for Medicare and Medicaid Services, the re-review process, and SMART Act changes that affect claims occurring after October 5, 2015. Moderated by Safety National’s Mark Walls, the panel also features Jake Reason with EK Health, Russell Whittle of Examworks, and Tony Comas with Burns White.

“The SMART Act allows for an appeal process for conditional payment disputes,” said Wilson.

The conditional payment process is also changing. “The big news is that Medicare will seek reimbursement for conditional payments prior to settlement,” Wilson said.

Medicare’s new contractor, Commercial Repayment Center, will issue conditional payment notifications when an entity indicates its ongoing responsibility for medical. “Payers only have 30 days to dispute notifications before a conditional payment demand goes out,” Wilson said. “To mitigate their exposure, payers should ensure their Mandatory Insurer Reporting data is complete and immediately respond to conditional payment notices.”

The California Workers Compensation and Risk Conference will be held September 30 through October 2 at the St. Regis Hotel in Dana Point, Calif., and more information is available at http://www.cwcriskconference.org.

About Tower MSA Partners

Headquartered in Delray Beach, Fla., Tower MSA Partners’ services include pre-MSA Triage, MSAs, physician peer reviews, CMS submissions, MSA administration, medical cost projections, life care plans, conditional payments, and Section 111 reporting. With more than 50 years combined experience in pharmacy, legal oversight and medical care, Tower proactively stages claims, working collaboratively with clients to identify issues and intervene to modify outcomes. Tower remains involved in the claims, through final resolution, MSA and/or other settlement. This model enables Tower’s clients to provide better care to injured workers, reduce claim and MSA costs, and obtain CMS acceptance of the MSA. For more information, visit www.TowerMSA.com and www.MSPComplianceBlog.com.

Contacts
For Tower MSA Partners
Helen Knight, (813)690-4787
helen@kingknight.com

You may view the original article here.

Lyrica – High Claim Cost Doesn’t Necessarily Mean High Dollar MSAs

January 13, 2016

opioid guidelines

Lyrica is one of the most widely prescribed ‘pain’ medications in the workers’ system. Unfortunately, it is also one of the most expensive. Add to that the fact that it is typically prescribed ‘off label’ for injured workers, and you’ve got a recipe for high claim cost.  But will this high dollar monthly drug spend translate to a high dollar MSA?

Lyrica’s 2016 price increase

Lyrica is among more than 100 drugs that saw price increases as of Jan. 1, 2016. Drug maker Pfizer said the company had raised the price by a whopping 9.4 percent this year. That follows the 20.5 percent increase in its average wholesale price just two years ago. With patent protection firmly in place, a generic version is not expected for at least two years.

While workers’ compensation stakeholders seek medical treatments that result in the best outcomes for injured workers, and off label drug use is common in both workers’ comp and group health, starting with an off-label medication is unnecessary. First-line therapy should be those medications that are FDA-approved for the patient’s condition.

Lyrica’s off label use

Lyrica is FDA approved for only a limited number of conditions, not chronic pain in general. The Food and Drug Administration has indicated the drug for pain associated with diabetic peripheral neuropathy, post-herpetic neuralgia, partial onset seizures, fibromyalgia and neuropathic pain associated with spinal cord injury.

If you have a claimant on Lyrica who does not have any of the above conditions, Medicare WILL NOT cover it — meaning that while you, the payer, may foot the bill as part of your monthly claim spend, Lyrica would NOT be included in the Medicare Set Aside should you move toward settlement. Many medical providers, as well as insurance carriers, are unaware that the medication is not covered by Medicare for off-label uses.

Tower MSA recently saved a client $179,000 after confirming Lyrica was being prescribed off-label and, therefore, should not be included in the MSA. That’s just one example of a high dollar claim cost that did not translate to a high dollar MSA projection.

What to do

Lyrica is just one of the many medications prescribed off-label in the workers’ compensation system. There are many others, like Lidoderm patches, Terocin cream, ACTIQ, Abilify…. all  extremely expensive drugs that are not decreasing in price anytime soon.

If you’re unsure as to whether a drug is being prescribed off label, contact Tower and ask the question.  If you’re considering settlement, you might also consider Tower’s Pre-MSA Triage.  This service identifies unnecessary/inappropriate treatment and recommends claim specific intervention strategies to optimize claim cost before the MSA.

Whether a recommended intervention involves clarification that a medication is being prescribed for an off label use,  contact with the treating physician to obtain discontinuation of medications not intended for long term use, or a complete physician peer review with peer to peer collegial dialogue, Tower’s MSP Automation Suite drives the process, tracking progress through completion. As a result, payers can better manage treatment and proactively lower their costs before discussions of the MSA ensue.

Conclusion

Never underestimate the value of a good doctor in optimizing claim outcomes.  Payers should identify good physicians through data analytical resources and tools, and not settle for mediocrity.   Next, work with your PBM to established and enforce pharmacy guidelines when authorizing treatment.  Finally,  be proactive in utilizing state jurisdictional options to avoid inappropriate treatment.

Optimal care, cost and compliance can be achieved.