Tower MSA Partners Archives

Tower Releases White Paper on Future Medicals in Liability Settlements

December 13, 2022

woman sitting in a dr waiting room to discuss her liability case

This past October, the Centers for Medicare and Medicaid Services (CMS) withdrew its proposed rule on future medicals in liability settlements from review by the White House Office of Information and Regulatory Affairs (OIRA). (See CMS Withdraws Proposed Rule on Future Medicals in Liability Settlements).

Right now, we don’t know if a proposed rule around Liability Medicare Set-Asides (LMSAs) will be reworked and resubmitted to OIRA for consideration soon or whether CMS is closing out regulations around liability settlements and future medicals for the foreseeable future.

Given the lack of guidance from CMS, we thought this was an opportune time to update our white paper, Navigating through the Fog: Medicare, Future Medicals & Liability Settlements. Authored by Tower’s Chief Compliance Officer Dan Anders, the paper explores CMS authority to regulate future medicals and provides guidance to the liability practitioner as to how to address future medicals at the time of settlement.

AASCIF Publishes Tower Article on MSA Submit vs. Non-Submit Debate

December 12, 2022

In its fall newsletter, the American Association of State Compensation Insurance Funds (AASCIF) published an article entitled “Despite the Controversy, MSA Submission is Still Okay.” Written by Tower’s Chief Compliance Officer, Dan Anders, the article details the pros and cons of Centers for Medicare and Medicaid Services (CMS) approval of an MSA.

As the article concludes, “While the submit vs. non-submit dispute will undoubtedly continue, the MSA approval process allows parties to obviate the risk of shifting future injury-related medical care to Medicare by obtaining a stamp of approval.” Recognizing that the submission process can sometimes increase settlement costs, the article provides tips on obtaining a quick CMS MSA approval and reducing cost drivers.

Post-Settlement Care, Cost and Compliance Through Professional Administration

December 6, 2022

Picture of Medicare billing statement for Section 111 WCMSA reporting.

While workers’ comp payers invest considerable resources to manage and settle claims, they don’t always prepare Medicare-eligible injured workers for life after settlement. These patients have usually been in the workers’ comp system for several years. And the system has paid for their injury’s treatment and medication, and in some cases, coordinated their care.

When their claim closes, all that comes to an end. Injured workers are on their own to navigate the healthcare system and handle the bills. They need to pay for doctors’ visits and medication from their Medicare Set-Asides (MSAs). They also need to make sure Medicare doesn’t have to pay for their injury-related care. Post-settlement compliance responsibilities can be overwhelming.

Tower’s recent Premier Webinar: Care, Cost & Compliance Through Professional Administration featured Nicole Chappelle who has nearly 30 years’ experience in all aspects of claims management — before and after settlement. Now Vice President of Settlement Solutions for Tower’s partner Ametros, Nicole joined our Chief Compliance Officer Dan Anders for what could be our liveliest webinar yet.

Here are some takeaways:

Injured workers who are also Medicare beneficiaries can self-administer their MSA or use professional administration.
The Centers for Medicare and Medicaid Services (CMS) highly recommends professional administration for beneficiaries who take opioids and other frequently abused controlled substances.
Professional administration is available for MSAs that are CMS-approved and for those that are not submitted for CMS approval.
Payers typically cover Ametros’ one-time professional administration fee of $1,000.

Although CMS allows beneficiaries to self-administer an MSA, it strongly recommends they consider professional administration. So do we.

First, MSA funds can only be used to pay for Medicare-covered medical treatment and prescription drugs related to the claim. Learning what Medicare does and doesn’t cover is challenging at best. It’s even more confusing for an injured worker whose workers’ comp program paid for items that Medicare does not cover, such as a sophisticated power wheelchair, home healthcare, and off-label use of certain medications. Will the typical, older injured worker understand this?

Additionally, MSA funds must be kept in an interest-bearing checking or savings account and used only for the aforementioned Medicare-covered care related to the claim. Even the interest needs to be used for this purpose.

The administrator has to maintain itemized medical and pharmacy receipts, bank statements, and other records for each transaction from the MSA account. An attestation of these expenditures needs to be submitted to the Benefits Coordination & Recovery Center (BCRC) every year.

If the MSA is funded with an annuity and funds run out in any given year, the administrator must report the temporary exhaustion of funds to the BCRC. Should funds be permanently exhausted, the administrator needs to send the BCRC a final attestation letter confirming the situation.

If MSA funds remain when the beneficiary dies, the executor or administrator is to notify the BCRC and pay for outstanding (related) medical bills from the fund. But would an executor know to do this?

Some things are best left to professionals.

If you’d like to see the whole webinar, please contact Dan Anders at daniel.anders@towermsa.com for the link and slides. He’s happy to connect you with Nicole Chappelle, too. And, as always, if you have any questions about MSAs, post-settlement compliance, or other Medicare Secondary compliance issues, get in touch with Dan.

Build a Better Tower: Partnerships Speed Settlements of Workers’ Comp Claims with Medicare Set-Asides (towermsa.com)

CMS Announces Upcoming Section 111 Webinar / WCMSA Reference Guide Update Released

November 15, 2022

Tower MSA Partners covers CMS new guide on Medicare conditional payment appeals and the upcoming Section 111 reporting webinar.

The Centers for Medicare and Medicaid Services (CMS) recently published a Section 111 reporting webinar notice and an update to its CMS WCMSA Reference Guide.

CMS Section 111 Reporting Webinar

CMS will hold a Section 111 NGHP Webinar on December 6, 2022, at 1:00 PM ET. The notice says:

CMS will be hosting a Section 111 NGHP webinar. The format will be opening remarks by CMS, a presentation that will include NGHP reporting best practices and reminders followed by a question and answer session. For questions regarding Section 111 reporting, prior to the webinar, please utilize the Section 111 Resource Mailbox PL110- 173SEC111-comments@cms.hhs.gov.

The webinar notice can be found here. We encourage anyone involved in the management of Section 111 reporting to tune into it. Please note that there is no pre-registration; instead, the link and call-in phone numbers are on the notice. You just log in shortly before the webinar’s start time.

WCMSA Reference Guide Update

The update to CMS’s WCMSA Reference Guide, Version 3.8 provides for changes to the re-review criteria. (Because CMS does not have a formal appeals process after an MSA determination, it allows what are called re-review submissions). Currently, CMS allows for re-reviews for mathematical errors and missing documentation. It has now added a section for submission errors which provides:

Submission Error: Where an error exists in the documentation provided for a submission that leads to a change in pricing of no less than $2500.00, a re-review request may be made by submitting updated documents free of errors that caused the original review outcome. Amended documents must come from the originators with appropriate notation to identify that the error was corrected, along with the date of correction and no less than hand-written “wet” signature of the correcting individual. Note: This submission option is only available for approvals from September 1, 2022 forward.

Examples include, but may not be limited to: medical records with incorrect patient identifying information or rated ages where the rated-age assessor provided incorrect information in the rated-age document.

Rather than applying to submitter errors, this addition to the re-review policy appears to account for errors in the documentation that was provided to the submitter, such as a rated age or medical records.

Tower conducts a thorough review of all relevant documentation when the MSA is prepared and submitted. Consequently, documentation errors are identified and corrected before MSA submission. As such, we expect to make minimal use of the Submission Error Re-Review.

CMS also added a new section entitled Re-Review Limitations:

16.2 Re-Review Limitations

Note: The following re-review limitations are only available for approvals from September 1, 2022 forward.

Re-review shall be limited to no more than one request by type.

Disagreement surrounding the inclusion or exclusion of specific treatments or medications does not meet the definition of a mathematical error.

Re-review requests based upon failure to properly review already submitted records must include only the specific documentation referenced as a basis for the request.

It appears that the long-time policy of unlimited re-reviews has come to an end. We understand CMS’s statement that a re-review “shall be limited to no more than one request by type” to mean one re-review is allowed for a mathematical error, one for missing documentation, and one for a submission error.

CMS’s intention for stating that a “disagreement surrounding the inclusion or exclusion of specific treatment or medications does not meet the definition of a mathematical error” is not clear. While perhaps not a math error, when medical records from a treating physician clearly say surgery is no longer recommended or medication has been discontinued but CMS includes such treatment or medication in the MSA, we submit it as an error.

Tower has submitted numerous re-review requests to remove or modify treatment or medication from the MSA based on treating physician statements in the medical records. Tower has a 68% success rate with re-reviews when CMS previously issued an MSA counter-higher, proof that these are reasonable requests. We hope the addition of Section 16.1 does not signal CMS’s intention to reject these reasonable re-review requests.

If you have any questions, please do not hesitate to contact Dan Anders, Tower’s Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

For the First Time, CMS Releases Key Metrics on WCMSA Review Program

November 9, 2022

Person pointing out metrics on a posterboard to measure Medicare Set Aside.

The Centers for Medicare and Medicaid Services (CMS) recently released data that provides insight into its Workers’ Compensation Medicare Set-Aside (WCMSA) reviews. This is the first time CMS has released such detailed metrics.

CMS shared statistics for a 3-year period of 2020 through 2022 (CMS’s fiscal year ends on Sept. 30). The data compared proposed MSA amounts with the CMS-recommended amounts (what we typically call the “approved” MSA amounts). The data can be found here.

MSA reviews are down

In 2020 CMS completed 16,517 reviews and by the FY end of 2022, this had dropped to 13,752 reviews, a 17% decline.

The reason for the decline is up for speculation. There may have been fewer settlements and thus fewer MSAs during the pandemic. However, NCCI’s data* show that claim frequency only declined by about 1% when 2020 and 2021 are considered together.

Another theory is that the reduction reflects a trend of settling parties choosing not to submit the MSA to CMS for approval. Whatever the reason, there has been less engagement with the CMS WCMSA review program.

Review Methodologies Remain Consistent

When CMS disagrees with a proposed MSA amount it issues a counter-higher with an amount it recommends for the MSA allocation. The data provided by CMS show that the variance between total MSAs proposed versus recommended change was 13% (2020), 15% (2021) and 14% (2022). This consistency of result is because CMS’s WCMSA review methodologies have remained largely the same over the last several years.

Average Recommended MSA Is Steady

The year-over-year data show very little change in the average recommended MSA amount from $84,563.33 in 2020 to $81,571.75 in 2022.

A Billion Dollars a Year

The CMS data show that the amount the agency consistently recommends for all the MSAs comes to over $1 billion annually. However, this does not necessarily represent $1 billion in savings to Medicare. Savings result when the MSA is funded in a settlement and the MSA funds are expended for injury-related medical care that Medicare would otherwise cover.

How Tower’s MSAs Stack Up

The release of these statistics gives us a unique opportunity to compare Tower CMS-approved MSAs against all CMS-approved MSAs.

Average CMS-Approved MSA (2021 numbers):

CMS: $80,741 Tower: $54,956

Tower’s CMS-approved MSAs are 32% lower than the CMS average approved MSA

And if we isolate just the prescription drug component of the MSA.

Average CMS-approved Rx Amount in MSA (2021 numbers):

CMS: $20,916 Tower: $14,079

Tower is 33% lower than the CMS average for the prescription drug component.

These comparisons prove that Tower’s MSA allocation methodology along with our focus on cost mitigation through interventions, such as our Physician Follow-up service, reduce MSA allocations. Simply put, what this means to our partner clients is millions of dollars in savings. These metrics also show that cost reductions can be obtained, even when payers choose the CMS MSA approval process.

The release of data on CMS programs has been a policy initiative of the National Medicare Secondary Payer Network (MSPN), to which Tower belongs. We are pleased that MSPN’s efforts have resulted in this release.

We also thank CMS for publishing these statistics. Hopefully, it will become an annual report that includes more metrics on WCMSA reviews, such as the percentage of MSA proposals that are developed for information post-submission. It would also be interesting to learn how many MSAs are funded in a lump sum versus those funded via an annuity. In addition, MSPN is interested in metrics surrounding Section 111 reporting and Medicare conditional payments.

If you have any questions about this report or anything else on MSP compliance or MSAs, please feel free to contact Dan Anders, Chief Compliance Officer, at Daniel.anders@towermsa.com or 888.331.4941.

*See Rabb, W., (2022, May 11). “Claims Frequency Up for 2021, but Workers’ Comp Profitability ‘Unprecedented,’” Insurance Journal.

CMS Withdraws Proposed Rule on Future Medicals in Liability Settlements

October 18, 2022

CMS withdraws rule on future medicals in liability settlements affecting LMSA guidance

On October 13, 2022, the Centers for Medicare and Medicaid Services (CMS) withdrew its proposed rule on future medicals in liability settlements from review by the White House Office of Information and Regulatory Affairs (OIRA review and approval is required before a proposed rule is published).

While never published to the public, the proposed rule was expected to provide guidance regarding obligations associated with future medical items in liability cases. It was commonly believed these obligations would include the use of a Liability Medicare Set-Aside (LMSA), similar to MSAs used in workers’ compensation, in certain situations.

What is uncertain now is whether a proposed rule around LMSAs will be reworked and resubmitted to OIRA for consideration soon or whether CMS is closing out regulations around liability settlements and future medicals for the foreseeable future. This is the second time CMS has withdrawn a rule on LMSAs, with the first withdrawn in 2014.

Practical Implications

While the lack of guidance around future medical obligations to CMS may have frustrated parties to liability settlements, these parties could have been even more frustrated if CMS had issued rules. As it is, parties in liability cases continue to have much more discretion in determining how to best consider Medicare’s interests in future medicals at the time of settlement than do parties in workers’ compensation cases.

What should settling parties do, given that no CMS LMSA review policy or process currently exists? Please reference Tower’s “Navigating Through the Fog: Medicare, Future Medicals & Liability Settlements” as a starting point. Of course, always feel free to contact me, Dan Anders, for consultation at Daniel.anders@towermsa.com or 888.331.4941.

CMS Rulemaking Notices Provide Possible Timeline for Criteria on LMSAs and Reporting Penalties

Automation has its place, but it can’t replace people in MSP compliance

October 3, 2022

Automation in MSP compliance cannot replace human expertise in complex claims

Technology isn’t everything. It may seem hard to believe that I have said this because most of my career was steeped in technology.

In my past life, I developed automation systems for pharmacies and workers’ comp pharmacy benefit management (PBM) models. Rules-based adjudication platform allowed for automatic Rx fills for many prescriptions, but also supported trigger-based escalation for the outliers to request authorization or have an expert take a closer look. The time saved and convenience provided were astounding.

When we started Tower, Kristine Dudley and I automated much of the paper-intensive world of Medicare Set-Asides, and also integrated the 3 major components of Medicare Secondary Payer compliance, Section 111 Mandatory Insurer Reporting, Conditional Payments and Medicare Set Asides, into a single platform. I believe we were the first to do that.

Our platform, Tower’s MSP Automation Suite, was built based on state workers’ compensation statutes overlayed with WCMSA guidance, metrics-based KPI tracking and intervention / escalation triggers that supported MSP best practices. By seamlessly integrating Section 111 reporting, conditional payment resolution, and MSA preparation into a single, all-encompassing system, our MSP Automation Suite ensures that nothing drops through the cracks, no field goes unpopulated, problem cases can be identified, and deadlines are met.

Tower’s MSP Automation Suite captures, stores and manages all data points, integrates with ANY claims system, enables clients’ business rules to be overlaid onto ours, and gives our clients end-to-end visibility into Medicare and claim information. Our system also leverages embedded triggers to escalate medical and pharmacy issues, prompting a review for intervention. In short, Tower’s MSP Automation Suite leverages the best of automation until technology intersects with the need for expertise. This allows our team to manage, track and drive MSP compliance from the moment a Medicare beneficiary is identified through the claim’s closure.

Do we love automation? You bet we do.

But we realize automation can’t do everything. MSP compliance has always – and will always – require a high degree of consultative expertise. You can’t just capture and populate data fields, and automatically “pop” out an MSA that supports aggressive cost mitigation that is both CMS-approvable and facilitates settlement.

While many workers’ compensation claims move through the system seamlessly, others are “messy”. Body parts may be denied, additional claims may exist, co-morbid conditions may complicate treatment, surgeries, medical treatment and medications may be prescribed inappropriately or ICD10 codes may be too general or inconsistent with the treatment being paid by the carrier. These are just a subset of the rules-based triggers built into our system so that claims warranting attention are automatically escalated to a human expert to dig through files, examine causation questions, and probe open-ended medical care and contradictory medical records.

Clients need their calls, emails and questions answered by real people, and quickly. Complex conditional payment matters call for conversations … with a knowledgeable partner who shares your goals.

Our automated system escalates medical and pharmacy issues, but then you need a professional with specialized knowledge and experience to recommend the best intervention. And to implement it.

One of our most effective interventions created by Tower is our Physician Follow-up. Guess what? This is performed by people, people who have the patience and commitment to keep trying to talk to the provider. If you’ve tried to call and talk to your own doctor lately, you know what a challenge this can be.

These professionals have the knowledge and soft skills needed to delicately point out vague notes and open-ended recommendations in medical records. And they must be able to persuade the provider to clarify their treatment and prescriptions. Drafting a jurisdiction-specific statement for the provider to sign requires yet another human skill set.

If I had to name the one aspect that drives Tower’s success, I’d have to say service. Our technology enables us to respond quickly, anticipate issues, and proactively address them, but it’s the people, their attitudes, and their expertise our clients value the most.

The common thread in our client testimonies are service and partnership. Clients are “very impressed with [Tower’s] level of communication and availability to help answer questions,” and they say, “they truly listen; listen to understand and not just to respond.”

Perhaps this person sums things best: “They have advanced technology and certified specialists to ensure no stone is unturned.”

Insurance carriers, self-insureds and TPAs are dealing with shortfalls in staffing. There’s more pressure on the experienced adjusters, and the new hires need all kinds of support to get up to speed on MSP matters. Tower MSA Partners is here to help. That’s what the Partners part of our name means.

We are proud of our technology, and we recognize when to leverage it and when automation must give way to consultative expertise. There is a need for partnership with real people who care about your claim closure and settlement and can ensure that happens with the right balance of care, cost and compliance.

If you have any questions or just want to talk about partnership opportunities, the expertise of our people, or our technological capabilities contact me at rita.wilson@towermsa.com.

Tower MSA Partners’ WCI-TV Interviews Reveal How Workers’ Compensation Companies Use Claims Data

August 19, 2022

The workers’ compensation industry has extolled the promises of data analytics and automation for years.

But how are organizations really using claims data? What strategies have worked best? And what have they learned? Several executives will share their experiences during WCI-TV interviews sponsored by Tower MSA Partners.

Guests include Dave Strange, the Yellow Corporation’s Workers’ Compensation Manager and Greg Hamlin, Senior Vice President, Resolution with Berkley Industrial Comp. Ametros CEO Porter Leslie and Alisa Hofman, Vice President of Workers’ Compensation and Medicare Practices for Arcadia will discuss the use of data during and after settlement.

In addition, Tower’s Chief Compliance Officer Dan Anders and Chief Operations Officer Kristine Dudley will share how the technology driven company uses data to streamline Medicare Secondary Payer compliance, protect clients from penalties, and optimize Medicare Set-Asides.

Tower has been the exclusive sponsor of WCI-TV since it first aired in 2015. WCI-TV airs throughout the convention center, in hotel guest rooms and shuttles, on You Tube and CI’s website. Tower’s interviews will also be shared on the company’s LinkedIn page.

The 76^th Annual WCI Conference will be held August 21-24 at the Orlando World Center Marriott. For more information, please see https://www.wci360.com/conference/.

Is a CMS-approved $0 MSA Still Possible?

July 26, 2022

WCI TV interviews on workers compensation claims data analytics and insights

A common question we receive is whether a CMS-approved $0 MSA is still possible. The answer is, yes– if it meets the criteria.

There are three different ways a $0 MSA can be obtained, each with its own criteria and documentation requirements.

Denied Claim $0 MSA

This is a $0 MSA based on a completely denied workers’ comp claim when no payments have been made for medical treatment or indemnity. In certain jurisdictions, such as California, some medical payments can have been made during a statutory investigating period. Payments for non-treatment purposes such as IMEs, case management and medical records copies do not impact the ability to obtain a $0 MSA approval.

This type of $0 MSA has significant documentation requirements:

1. Claim Payment History

A claim payment history printout, even if blank, representing payments since the inception of the claim. All payments must be itemized.
Printout must be divided into categories for medical, indemnity and expenses with subtotals for each category and a grand total listed. This printout needs to include the print or run date.
If the claim payment history does not meet the above requirements, then Tower will work with you to identify alternative documentation that meets CMS requirements.

2. Draft or final settlement documents and court orders or rulings or a statement that no such documents exist (see below Financial Detail and Denial Letter). CMS recently added a requirement that there must be a proposed or agreed-to settlement. Importantly, while CMS requires a proposed settlement, it will reject the $0 MSA if the settlement is finalized, for example with court or commission approval, before CMS’s review and approval of the $0 MSA.

3. First Report of Injury or a statement that no such document exists (See below Financial Detail and Denial Letter).

4. Financial Detail and Denial Letter – At the time of submission Tower will draft a letter for the client to sign that confirms the denial of the claim and any other necessary explanations, such as why no First Report of Injury is available.

5. Medical Records: As with a regular MSA, medical records for the past two years must be provided with the submission.

6. CMS Consent to Release form executed by the claimant.

Accepted Claim $0 MSA

This is a $0 MSA based on medical documentation supporting no further need for injury-related treatment. In the WCMSA Reference Guide, CMS provides as follows:

The individual’s treating physicians conclude (in writing) that to a reasonable degree of medical certainty the individual will no longer require any Medicare-covered treatments related to the WC injury.

In practice, CMS accepts treating physician statements that say the injury-related treatment has resolved or returned to baseline (when there was a pre-existing condition) and that no further injury-related treatment will be necessary as sufficient to support the $0 MSA.

Keep in mind that CMS will not accept the physician’s statement unless it is consistent with the treatment records/notes. For example, if the physician states the injury-related has resolved, but treatment notes document ongoing pain to the relevant body part, CMS is unlikely to approve a $0 MSA. Also, if the injured worker will require a revision or replacement to a body part, e.g., a knee replacement, a $0 MSA will not be approved.

In addition to the physician statement, a claim payment history, medical treatment records and an executed Consent to Release are required.

Judicial Decision $0 MSA

CMS will accept a judicial decision after a hearing on the merits of the case as a basis for a $0 MSA. This can be on a completely denied claim where the judge upholds the denial of the claim or an accepted claim where the judge finds future medical treatment, if any, is unrelated to the work injury. The key here is the decision is “on the merits.” If it in any way looks like an agreement between the parties and the judge just stamped their approval, CMS will not accept it.

In addition to the judicial decision, a claim payment history, medical treatment records and an executed Consent to Release are required.

While there are strict documentation requirements, these $0 MSA approvals remain available for workers’ compensation cases meeting the applicable criteria. Please contact Tower MSA Partners at referrals@towermsa.com or (888) 331-4941 to refer a claim meeting these requirements or for further consultation.

The DEA Finally Decides To Reschedule Hydrocodone

August 27, 2014

Last week the DEA released a final rule on the rescheduling of hydrocodone removing it from the schedule III controlled substances list in favor of a schedule II designation. To be clear, this decision specifically addresses hydrocodone combination products (i.e., hydrocodone-acetaminophen formulations such as Vicodin) as hydrocodone by itself has always been a schedule II drug.

The new parameters surrounding the prescribing of hydrocodone under the more restrictive schedule II classification will go into effect on October 6, but the decision by the DEA in conjunction with the Assistant Secretary for Health of the U.S. Department of Health and Human Services has been a long time coming. Hydrocodone combination products (HCP’s) have been schedule III since the Controlled Substances Act was passed in 1970 despite, as mentioned, the fact that hydrocodone itself has always been a schedule II drug. The thought initially was that by combining hydrocodone with another substance such as acetaminophen would diminish the abuse potential, but in the DEA’s final order they actually point to several different statistics that definitively portray just the opposite. Perhaps the most eye opening of these statistics tells us that high school aged children have actually abused Vicodin at twice the rate of Oxycontin, a more tightly controlled schedule II drug that has in the past, grabbed a lot more of the headlines.

Not surprisingly, there was a lot of pushback from the pharmaceutical community as well as some from the medical community throughout this process which has taken 15 years to come to fruition (the original petition was submitted by a physician in 1999). This dissent however, is misplaced and perhaps even irresponsible considering hydrocodone is the most prescribed drug in the United States. Last I checked, heart disease was the biggest killer in this country, not pain, yet hydrocodone is prescribed more than even ACE inhibitors (for hypertension) or statin drugs (to lower cholesterol). And if that is surprising to you try to wrap your head around this: the United States is comprised of about 4% of the world’s population yet we use 99% of the world’s hydrocodone.

The affect this will have on the workers compensation industry could prove to be significant. In terms of PBM’s who commonly push for mail order distribution, schedule II drugs have restrictive policies not conducive to this type of service. It would therefore be a good idea to check with your PBM to ensure that they are actively transitioning all applicable injured workers.

A second implication could be in regards to the widely utilized Official Disability Guidelines (ODG) which have long classified several HCP’s as Y drugs (recommended for first line treatment) within their workers compensation formulary. If changed to N drugs, those HCP’s would be subject to immediate utilization review in states such as Texas and Oklahoma that have instituted a closed formulary.

In my world of Medicare Secondary Payer compliance, it’s tough to say exactly where the effect of this rescheduling will be felt, but there are some trends that I hope we begin to see starting with less hydrocodone on MSA’s. It is easy to get caught up in cost drivers and how to mitigate unnecessary medical treatment in my line of work, and rightfully so when a prescription that was never meant to be maintained long term must be allocated for because it is part of the current treatment plan. But oftentimes, payers tend to overlook or not focus on HCP’s due to their relative low cost in comparison to some of their counterparts such as Oxycontin, Opana or Actiq. The result of that is we are consistently including long term use of hydrocodone-acetaminophen (for example) within MSA allocations in spite of the fact that no opioid has ever been recommended for long term use. This sort of tradeoff is unavoidable at times, but I will still hold out hope that the DEA’s most recent stance to reschedule hydrocodone combination products will prove to have a significant impact on the misuse and abuse of prescription painkillers, not just in our little world of work comp, but far reaching into our society as a whole.