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What Can Workers’ Comp Learn About Compounds From the Meningitis Outbreak?

October 29, 2012

As of Tuesday, the Centers for Disease Control and Prevention reported 317 meningitis cases across several states, including 24 deaths. According to a preliminary report released on Monday, investigators from the Massachusetts Department of Public Health found “serious health and safety deficiencies” at the compound pharmaceutical lab (NECC) tied to the fungal meningitis outbreak.

Investigators also found a leaky boiler adjacent to the clean room with a pool of water creating unsanitary conditions inside the Framingham, Mass.-based New England Compounding Center. Culture results from that potential contaminant are still pending, the report states.

Tacky mats used to trap dirt and other contaminants from workers’ shoes prior to entering a clean room “were visibly soiled with assorted debris,” according to the report from Massachusetts’ Executive Office of Health and Human Services.

Investigators also reported the compounding center distributed large batches of products in bulk, which was not allowed under the terms of its pharmacy license.

Managed Care Matters – Killing Compounds Update

According to Joe Paduda, “Although the FDA’s ability to regulate compounders is very limited, the agency studied compounds produced by12 different pharmacies a decade ago; a third of the products failed one or more standard quality tests. Another test in 2006 found the same results.”

We know that compounding is regulated at the state level as it is considered to be “the same” as any other form of pharmacy practice, all of which are state controlled. What is different about compounding, however, is that regulation of the compound itself, unlike FDA approval and regulation of standard drugs, is virtually non-existent. In his recent post, (http://www.healthstrategyassoc.com/wordpress/2012/10/killing-compounds/ ) Joe Paduda also notes, “Only two states – MO and TX – test compounded drugs, and their findings are alarming indeed. The strength of the potions concocted by compounders can vary greatly, with Texas determining a quarter of the compounds they tested were “too weak or too strong” and MO finding the potency is as much as three times higher than the compound was supposed to be.

What Can Workers’ Compensation to Do Protect Its Patients?

Compounds represent one of the most dangerous and fraudulent forms of medication dispensing. That being said, compounds can also be extremely beneficial when medically necessary, and in the right environment of audits and controls.

Compounds are difficult to analyze value and benefit. As such, they are never indicated for pain management in Evidence Based Medical (EBM) guidelines such as the Official Disabilities Guidelines (ODG). Compounds are not approved or regulated by the FDA, but are allowed based on individual state pharmacy regulations.

While there are exceptions, as a general rule compounds should never be authorized and/or covered without consideration of the following intervention strategies:

If Utilization Review (UR) is a part of the state regulatory landscape, compounds should be sent through UR before being authorized for fill the first time.
If the UR reviewer deems the compound to be unnecessary, immediately direct your PBM to exclude it from the patient’s formulary.
If UR isn’t an alternative, escalate the authorization request to a nurse, clinician or physician to request a determination of necessity and appropriateness based on the state’s designated treatment guidelines.
As an example, for states that follow ODG, compounds would be indicated as necessary and appropriate ONLY in the following situations:
1. An indicated first line therapy was tried and failed,
2. The patient has an allergy to an inactive ingredient of a more traditional form of a medication.

At the claim level, we cannot protect our patients against every danger, clinical oversight and scam artist seeking to benefit financially from the workers’ compensation system. By consistently following the guidelines available, however, and encouraging more states to implement treatment guidelines like ODG, we can better position our companies and our patients to achieve the best in care, cost and compliance.

Is an Illegal Immigrant Entitled to Workers’ Compensation Benefits?

Is an illegal immigrant working in this country entitled to benefits under the Workers’ Compensation statutes? This question was answered in the affirmative in the Delaware Superior Court case, Del. Valley Field Servs. V. Ramirez, No. 12A-01-007-JOH (Sept. 13, 2012).

Saul Ramirez began working as an independent contractor in April 2010, and then working as a regular employee an added to payroll in January 2011. Mr. Ramirez’s boss requested a Social Security number in order to include him on payroll. Responding to that request, Mr. Ramirez furnished a fake Social Security card.

Shortly after being converted to a full-time employee, Mr. Ramirez fell down some stairs and injured his back. The accident was witnessed by the company’s president and reported the accident. It was determined by the treating physician that Mr. Ramirez was totally disabled.

In February, the company was informed by the payroll service that Mr. Ramirez’s Social Security number was false and Mr. Ramirez was subsequently deported in March.

Employer argued that employee (Mr. Ramirez) was not entitled to Workers’ Compensation benefits because:

Employee’s “fraudulent inducement” in falsifying documents to gain employment;
Mr. Ramirez’s deportation suspended benefits;
If Mr. Ramirez could not be lawfully hired pursuant to federal immigration laws, the State’s workers’ compensation laws were preempted.

The Board rejected those arguments stating that despite Mr. Ramirez’s illegal status and falsifying documents, he still qualified as an “employee” under the Workers’ Compensation Act (“Act”). The information Mr. Ramirez falsified was not the type of information that would make him forfeit his rights as the falsification did not pertain to his health, work history, or prior injuries.

Next, the Board stated that federal law did not prohibit the award of benefits to an illegal alien. Also, the inability of Mr. Ramirez to return to the United States for treatment did not forfeit his right to benefits as he was not “refusing” treatment as defined in the Act.

The main issue in this case was not one of immigration law, it was labor law. Mr. Ramirez was hired by the company to perform work. He was injured on the job and required medical treatment. There was no dispute about the actual injury. The employer received the bargained-for benefit of the employment relationship. This case has been appealed to the Delaware Supreme Court.

Another state takes up the fight against Prescription Drug Abuse….

October 24, 2012

Fight Against Prescription drugs

Another state takes up the fight against Prescription Drug Abuse….
“Kentucky House Bill 1, sponsored by House Speaker Greg Stumbo, passed in a special legislative session this spring and went into effect July 20. The bill included multiple elements to prevent the abuse and diversion of prescription drugs and to enhance law enforcement’s tools to investigate illegal prescribing practices. Since its implementation, 10 pain management clinics have closed, prescriptions for some of the most-abused controlled substances are dropping, and a record number of investigations are under way into suspicious prescribing practices,

For workers’ compensation carriers and employers, this is a tremendous victory in the fight to prevent prescription drug abuse by injured workers. We believe more states should follow Kentucky’s lead.

When NOT to Authorize an Additional MRI

Additional MRI States that follow the Official Disability Guidelines (ODG) do not need to authorize an additional MRI
unless there are specific changes in pathology.
The ODG states that ³MRI¹s are test of choice for patients with prior back surgery,
but for uncomplicated low back pain, with radiculopathy, not recommended until after at least one month conservative therapy,
sooner if severe or progressive neurologic deficit. Repeat MRI is not routinely recommended,
and should be reserved for a significant change in symptoms and/or findings suggestive of significant pathology
(eg, tumor, infection, fracture, neurocompression, recurrent disc herniation).² (Bigos, 1999) (Mullin, 2000)
(ACR, 2000) (AAN, 1994) (Aetna, 2004) (Airaksinen, 2006) (Chou, 2007)

Things My Mother Taught Me

She taught me a LOT!

My mother taught me TO APPRECIATE A JOB WELL DONE.
³If you¹re going to kill each other, do it outside. I just finished cleaning.²

My mother taught me RELIGION.
³You better pray that will come out of the carpet.²

My mother taught me about TIME TRAVEL.
³If you don¹t straighten up, I¹m going to knock you into the middle of next week!²

My mother taught me LOGIC.
³Because I said so, that¹s why.²

My mother taught me MORE LOGIC.³If you fall out of that swing and break your neck, you¹re not going to the store with me.²

My mother taught me FORESIGHT.
³Make sure you wear clean underwear in case you¹re in an accident.²

My mother taught me IRONY.
³Keep crying, and I¹ll give you something to cry about!²

My mother taught me about the science of OSMOSIS.

³Shut your mouth and eat your supper.²

My mother taught me about CONTORTIONISTS.
³Will you look at that dirt on the back of your neck!²

My mother taught me about STAMINA.
³You¹ll sit there until all that spinach is gone.²

My mother taught me about WEATHER.
³This room of yours looks as if a tornado went through it.²

My mother taught me about HYPOCRISY.³If I told you once, I¹ve told you a million times, don¹t exaggerate!²

My mother taught me the CIRCLE OF LIFE.
³I brought you into this world, and I can take you out..²

My mother taught me about BEHAVIOR MODIFICATION.
³Stop acting like your father!²

My mother taught me about ENVY.
³There are millions of less fortunate children in this world who don¹t have wonderful parents like you do.²

My mother taught me about ANTICIPATION.

³Just wait until we get home.²

My mother taught me about RECEIVING.
³You are going to get it when you get home!²

My mother taught me MEDICAL SCIENCE.
³If you don¹t stop crossing your eyes, they are going to get stuck that way.²

My mother taught me ESP.
³Put your sweater on; don¹t you think I know when you are cold?²

My mother taught me HUMOR.³When that lawn mower cuts off your toes, don¹t come running to me.²

My mother taught me HOW TO BECOME AN ADULT.
³If you don¹t eat your vegetables, you¹ll never grow up.²

My mother taught me GENETICS.
³You¹re just like your father.²

My mother taught me about my ROOTS.
³Shut that door behind you. Do you think you were born in a barn?²

My mother taught me WISDOM.
³When you get to be my age, you¹ll understand.²

My mother taught me about JUSTICE.³One day you¹ll have kids, and I hope they turn out just like you!²

Court Urges Change in Florida Workers¹ Compensation Law

Court Urges Change in Florida Workers¹ Compensation Law. An appellate court is urging the Florida Legislature to reconsider a state law that makes injured employees pay employers¹ legal costs if they lose good faith workers¹ compensation appeals.
A three-judge panel of the 1st District Court of Appeal in Tallahassee made that recommendation in upholding such an order. It requires Gina Frederick to pay the Monroe County School District $11,834.
There¹s no dispute Frederick was hurt on the job, but two doctors disagreed on whether she had a permanent total injury. A medical adviser appointed by a compensation claims judge, though, offered the opinion she¹s not totally and permanently injured.
Frederick then withdrew her claim but still was ordered to pay the district¹s costs. The court noted the law on the other hand limits fees for workers¹ lawyers.
Copyright 2012 Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Source

Annual WCCP Holiday Conference!

October 18, 2012

Tower MSA Partners will be a sponsor of the Annual WCCP Holiday Conference! The event will be held at the Intercontinental Hotel in Tampa, FL on November 30, 2012. Registration begins at 7:30 a.m., with the conference starting at 8:30 a.m. After a full day of education, be sure to join us for our Sponsored Holiday Reception. This year we will be partnering with the Rough Riders for our 1st Annual Teddy Bear Drive. While this is the end of our educational season, it is one of the Rough Riders first events of the year, so let’s make it memorable! Challenge your peers to see who can donate the greatest number of bears while increasing your chance to win the WCCP Holiday Door Prize. Teddy bears must be between 12″ and 16″.

Upcoming CEU at the new Buca di Beppo.

Tower MSA Partners will be sponsoring an After Hours CEU at the new Buca di Beppo in the Governor’s Square Mall in Tallahassee this Thursday, October 18, 2012, starting at 5:30 P.M. We will be presenting “Important Deadlines” for a 1hr Law credit and “Tips For Employers On How To Save On WC Cost”. Heavy hor d’oeuvres and drinks provided to make sure no one goes hungry.

Good News From PA Court – ACTIQ Not Reasonable in Workers’ Comp Back Injury

October 10, 2012

The Pennsylvania Commonwealth Court, in a decision published late last month, seized upon Fentanyl (ACTIQ), a highly addictive opioid, 100 times more powerful than morphine, when it ruled specifically that Fentanyl lozenges were not appropriate as treatment for a workers’ compensation low back injury. According to defense counsel, Ronald A. Varga, the decision of the Court “could be significant” as it provides carriers with “a mechanism to cut of this medication and switch to something else”.

The original dispute occurred after Utilization Review findings concluded that the Fentanyl lozenge was not appropriate and necessary treatment for a low back injury because of its highly addictive nature and because its only approved use is listed as end stage cancer pain. The original decision, made by the Workers’ Compensation Board, found that the risk of addictive and potential danger to the patient is a valid and reasonable basis for the determination of the appropriateness and necessity of a treatment regimen. Upon appeal, however, divided Workers’ Compensation Appeals Board (WCAB) overturned the decision, noting that the availability of alternative treatment options “does not, in and of itself, render claimant’s current pain management unreasonable or unnecessary”.

The Commonwealth Court, in its reinstatement of the original ruling, noted the following:

1. The utilization review process is the sole method for determining if a disputed treatment is reasonable and necessary.
2. In making its determination of reasonableness and necessity, it is entirely appropriate for UR reviewer to consider the risk to the patient.
3. The reviewer in this case was within his rights to “consider whether it is reasonable and necessary for a provider to expose his patient to the level of risk presented by a medication”.
4. The weight and credibility of a utilization reviewer’s findings is for the workers’ compensation judge to decide.

As a resource for other employers, it is likely that we’ll see this decision cited as justification to contest the use of this very dangerous opioid. If an employer or insurance company can obtain objective medical opinion that the treatment the patient is receiving is highly addictive and there are alternatives to the use of narcotics, this case will certainly support an effort to challenge the prescription.

For more information on the decision and its implications, see https://ww3.workcompcentral.com/news/story/id/b8df217867f36a5641fbd85e9bcb5dd7s (subscription required).

CMS New WCMSA Decision Memo: TENS Units: Not Appropriate for Chronic Low Back Pain

October 5, 2012

Tens units not appropriate for low back pain

The Centers for Medicare and Medicaid (CMS) issued a new memorandum that will affect pricing determinations for TENS (Transcutaneous Electrical Nerve Stimulation) units for the treatment of Chronic Low Back Pain (CLBP) included within the Workers’ Compensation Medicare Set-Aside (WCMSA) that have been submitted to CMS for approval.

On June 8, 2012, CMS issued a new Decision Memo that defined CLBP as “an episode of low back pain that has persisted for three months or longer; and is not a manifestation of a clearly defined and generally recognizable primary disease entity.” CMS further stated that a TENS unit was not “reasonable and necessary for the treatment of CLBP under section 1862(a)(1)(A) of the Social Security Act.”

TENS is the use of stimulating pulses across the surface of the skin produced by a device to stimulate the nerves for therapeutic purposes. TENS help stimulate your body to produce higher levels of Endorphins. The TENS units are small, battery operated devices that deliver these stimulating pulses across the surface of the skin. It has been an ongoing dispute over the years as to whether TENS units do more than act like placebo’s, and whether they actually treat and cure CLBP.

CMSs New Pricing Determination will affect the WCMSA’s proposal as follows:

Workers’ Compensation cases settled prior to June 8, 2012:
“For those Workers’ Compensation cases settled prior to June 8, 2012, and where the settlement included pricing for TENS for CLBP, CMS will consider funds spent for TENS for CLBP by beneficiaries and claimants as being an appropriate expenditure of funds as part of the WCMSA.”
Workers’ Compensation Cases Settled After June 8, 2012:
“For those Workers’ Compensation cases that were not settled prior to June 8, 2012, and where the WCMSAs proposal includes funding for TENS for CLBP as part of the WCMSA, CMS will re-review the cases and remove pricing for TENS for CLBP. (Regional Offices shall obtain from Submitters requests for a case re-review, along with a signed statement indicating a settlement had not occurred prior to June 8, 2012.)”

It is important to note that in the event CMS does re-review a WCMSA for removal of a TENS unit for CLBP, the claimant may NOT use the funds from their WCMSA to pay for the TENS for CLBP. If a claimant uses the funds for the TENS, this would result in an inappropriate expenditure of funds.

For additional questions on the use of TENS units as treatment for chronic low back pain, and its implications on future medical treatment and the WCMSA, please contact Tower MSA Partners at 888-331-4941 or email us at info@towermsa.com. For the full text of the CMS Decision Memo, see Decision Memo for Transcutaneous Electrical Nerve Stimulation (TENS).