CMS Releases Training Document Regarding RX Drugs and the WCMSA Portal

By Mark Popolizio October 1, 2014

The Centers for Medicare and Medicaid Services (CMS) has released a training document regarding its upcoming plans to allow prescription drug information to be entered directly into the WCMSA Portal (WCMSAP).

A copy of CMS’ new training document can be obtained here.

This article outlines this new development as follows:

Background                

By Alert dated August 19, 2014 CMS announced that beginning October 6, 2014 WCMSA submitters will be able to enter prescription drug information directly into CMS’ WCMSA Portal.

As outlined in this prior Alert, some of the features related to this planned WCMSAP expansion include: new data entry pages to enter prescription drug information; a drug “look up” feature; and the ability to calculate expected drug costs.

For a more in-depth summary of CMS’ August 19th Alert, see ISO CP’s August Bulletin here.

In conjunction with this Alert, CMS advised that it would be releasing subsequent information sometime prior to the October 6, 2014 start date. Accordingly, CMS has now released its new training document.

CMS’ New Training Document

CMS released its new training document via PowerPoint format.

In terms of its set up, the training document provides information on the following features:

  • Prescription drug page
  • Redbook RX search page
  • Redbook RX detail page
  • RX historical detail
  • Revised case summary page

CMS explains how each of these features will work, what information will be provided, and provides other important details.

Highlights & Considerations

While CMS’ training document does not contain page numbers, as part of the below discussion the authors have assigned “slide numbers” to provide a more orderly discussion.

In assessing the actual content of the training document, several questions and considerations surface:

1. To start, the training document states that submitters choosing to use the portal will be “required, when applicable” to directly enter prescription drug information into the portal “prior to submission of a case using the portal.” (Slide 3).  This reference seems to suggest the submitters wishing to use the portal will have no choice but to utilize CMS’ new RX portal process.

2. The training document further suggests that submitters will have no discretion in terms of limiting the number of years for calculating the costs of a specific drug. (Slide 9)

Specifically, it is indicated that submitters will only be able to choose the frequency of prescription drug use (i.e. one pill per day, week, etc.). As such, it appears that the portal will automatically default to calculating the drug costs over the claimant’s lifetime.

Assuming that this will be the case, this restriction could prove problematic in that it would apparently prevent submitters from utilizing the WCMSAP in situations where the submitter believes a more limited calculation is appropriate; such as the case where prescription drug weaning is occurring or is recommended, or for other valid reasons.

3. With respect to what CMS refers to as the “look up” feature, it appears that this will not be accessible until the process for interaction with the portal is initiated relative to a specific settlement. That is, this feature would not appear to serve as a tool for the purpose of simply checking, or “looking up,” drug pricing short of actually submitting a WCMSA proposal.

Without this new process being operational yet, it is obviously difficult to really gauge how it will actually work in real time, and if any of the above considerations and concerns will come to fruition.

Nevertheless, assuming that CMS’ overall goal in adding this new feature is to improve the efficiency of the WCMSA review process, the above considerations (especially points #1 and #2 above) could ultimately cause submitters to reconsider using the portal in certain situations if the new process ends up limiting the flexibility to submit realistic assessments of a person’s expected post settlement prescription drug usage, or limits the ability to submit certain evidence or arguments in support thereof.

Lastly, assuming the “look up” tool will be limited as noted in point #3 above, this would appear to be a missed opportunity for CMS to provide parties with a tool allowing them to proactively identify the anticipated drug pricing that CMS would approve.

For More Information…

ISO CP will continue to monitor developments in this area and provide updates as warranted. In the interim, please feel free to contact me if you have any questions.


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.