The Centers for Medicare & Medicaid Services (CMS) issued an important alert on August 19, 2014. An issue of contention with the Agency by the Industry has been the pricing of prescription drugs. Typically allocations returned with a counter higher letter by the review contractor are due to a conflict for the proposed cost of pharmaceuticals. These discrepancies has led the Industry to seek out reforms from CMS for greater predictability. This Alert is a good start to improved transparency, and we at Franco Signor congratulate the Agency to taking this important step.
Effective October 6, 2014, a user for any “Work-In-Progress” case will be able to directly enter pharmacy information directly into the portal. This new tool will include the following features:
- New data-entry pages to provide users with the ability to indicate if a claimant is taking, or expecting to take prescription drugs as a result of the workers’ compensation injury.
- Look-up tool that allows the user to search by drug name, National Drug Code (NDC) or manufacturer name.
- Ability for user to select drug from look-up tool and add it to the portal case.
- Ability for user to enter frequency for anticipated medications (per day, week or month) and system will calculate expected drug costs.
Commentary: Franco Signor applauds this step by the Agency for prescription transparency. We believe it will help with predictability and hope that the Agency would consider expanding the tool for those matters that are not “Works-In-Progress”. If this tool could be expanded, allocations submitted will be in better alignment with CMS cost structure, and perhaps, only need to be adjusted based on the monthly Redbook Drug Reference that is in effect at the date of submission. As the Agency will announce further news as we near the implementation date of October 6, 2014, perhaps this enhancement will be considered.
Franco Signor is a leader in MSP compliance which includes the development and submission of WCMSAs. We adhere strictly to CMS requirements for the benefit of our clients. Counter high letters from review contractor can also occur because of incomplete documentation at submission. Our QA processes ensure a complete CMS submission which result in a high percentage of acceptance of the WCMSA. Call on us and we will show you how the Franco Signor difference can help you close claims.