CHALLENGE:
Case submitted to Tower for Pre-MSA Triage to assess Medicare exposure. In 2010, worker was doing electrical line work when he was struck by lightning. Injuries included electric shock with pain, insomnia, depression and seizure activity. Treatment included prescription drugs as follows: Hydrocodone/APAP (7.5 / 325 mg at 4 / day), Baclofen (muscle relaxant), Topamax (anti-seizure), Cymbalta (anti.depressant), Keppra (anti-convulsant), Naproxen (pain), Clonazepam (anti-anxiety). Cost drivers included Keppra and Topamax, both with generic available, but being prescribed, filled and paid by carrier as brand. Total MSA Exposure – $1,416,513.
SOLUTION:
As part of the standard Pre-MSA Triage process, Tower’s clinical team identified the key cost drivers, made recommendations within the context of the state of jurisdiction to optimize the drug regimen, documented recommendations to achieve the desired result, and calculated the optimized MSA value at $641,930. In this case, recommended next steps included Tower’s Physician Follow Up service to contact the injured worker and treating physician to request a change from ‘Brand’ to ‘Generic’ formulation for Topamax and Keppra. Tower’s legal team worked with defense to facilitate the switch by obtaining attestation of acceptance of the generic formulation by the injured worker (he had previously requested brand), then communicating with the prescribing physician to obtain written confirmation of the substitution of generic formulations of both drugs for the previously prescribed brand drugs.
RESULTS: $774,583 IN SAVINGS
With client approval, Tower used the information prepared with the Pre.MSA Triage, added the attestations obtained from both injured worker and physician noting that substitution was allowed for both Topamax and Keppra and finalized the MSA for submission to CMS. In its review, CMS accepted the attestations as confirmation of the change in drug therapy and approved Tower’s submitted MSA at $641,930. Total savings = $774,583. Pre-MSA Triage services are priced at 1/2 the price of the standard MSA. Physician Follow Up services are offered at no charge when completed in conjunction with MSA and CMS submission.
