CMS Releases New Policy Regarding Hydrocodone & Other Controlled Substances

By Mark Popolizio November 24, 2014

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The Centers for Medicare and Medicaid Services (CMS) has announced a new policy starting January 1, 2015 regarding hydrocodone combination products and other controlled substances in relation to WCMSA proposals.

As part of this new policy, CMS will require a minimum number of healthcare provider visits per year in situations where the claimant’s prescription regimen includes hydrocodone combination products or other controlled substances. CMS’ notice announcing this new policy can be obtained here.

This new policy can be outlined as follows:

Background

This policy change comes in direct response to the Drug Enforcement Administration’s (DEA) recent rescheduling of hydrocodone combination products.  Specifically, as outlined in CMS’ notice, the DEA in October, 2014 rescheduled all hydrocodone combination products from C-III controlled substances to C-II controlled substances.

In accordance therewith, CMS notes that this may result in more frequent provider visits for beneficiaries to obtain prescriptions for hydrocodone combination products, as refills are now prohibited. CMS further notes that C-IIIs required a new prescription after five refills or after six months, whichever occurs first. C-IIs require new prescriptions at intervals no greater than 30 days; however, a practitioner may issue up to three consecutive prescriptions in one visit authorizing the patient to receive a total of up to a 90 day supply of a C-II.

What is CMS’ New Policy?

In light of these updates, CMS has announced the following changes for all WCMSAs proposals submitted on or after January 1, 2015:

  • At a minimum, CMS will require that 4 healthcare provider visits be allocated per year when schedule II controlled substances (including hydrocodone combination products) are used continuously unless healthcare provider visits are more frequent per medical documentation.
  • WCMSA cases submitted to CMS before January 1, 2015, closed due to missing, incomplete and/or inadequate supporting documentation (or any other reason), and subsequently re-opened after January 1, 2015, will also be subject to a review that includes the C-III controlled substances changes due to rescheduling by the DEA.

What does this mean?

The drugs related to CMS’ new policy (hydrocodone and other schedule II controlled substances) are typically seen in cases involving orthopedic injuries. In terms of policy, CMS’ upcoming changes are relatively straightforward as the agency is basically setting a minimum allocation standard for healthcare provider visits in certain situations regarding schedule II controlled substances. From a more practical perspective, CMS’ upcoming changes will likely have minimal impact on WCMSA allocation costs in most instances since the minimum healthcare provider visits standard being established by CMS is essentially in line with typical allocation practices in these situations.

ISO Claim Partners will closely monitor this upcoming change and will provide updates if warranted.


Mark Popolizio

Mark Popolizio is the Vice President of MSP Compliance and Policy for ISO Claims Partners. Mark’s area of specialty is Medicare secondary payer compliance. He authors regular articles and provides educational presentations across the country on MSP issues. Mark's e-mail address is mpopolizio@iso.com.