The Centers for Medicare and Medicare Services (CMS) enhanced the Workers’ Compensation Medicare Set-Aside Arrangements portal (WCMSAP or portal) on October 6, 2014, by adding an additional step aimed at the collection of prescription information. This feature was established as part of the agency’s continuing efforts to automate and streamline the Medicare Set-Aside (MSA) review process. With that in mind, this article takes a closer look at the prescription medication enhancement and the impact it has had on CMS review procedures.
The WCMSAP was established in December 2011 to electronically receive and evaluate future medical and prescription drug costs for inclusion in an MSA. Before the creation of the WCMSAP, submitters were tasked with preparing “paper” submissions (often submitted using compact disc) to the Workers' Compensation Review Center (WCRC). The review process for paper submissions was cumbersome both for submitters and for CMS reviewers, resulting in MSA review times that regularly extended beyond six months to one year. In response to frustrations with the paper submission process, the WCMSAP was established as a web-based application, allowing qualified users to electronically submit MSAs to CMS for review and to monitor the progress of pending cases.
Establishment of the Rx Enhancement
While a complete examination of every aspect of the WCMSAP is beyond the scope of this article, the author has prepared a review of the most recent enhancement, as there is potential impact to the way CMS reviews prescription medications.
Logistical points to know:
- Affirmative notice: CMS requires users to affirmatively state (via check-box selection) whether the claimant is taking or is expected to take prescription drugs during the course of treatment for a workers' compensation injury.
- Information entered is not final: CMS makes a disclaimer at the outset of the Rx enhancement notifying users that the WCRC will review and make changes to the prescription regime as appropriate (WCMSAP User Manual Rev. 2015/5 January COBR-Q1-2015-V4.4, s. 11.5). In other words, the information entered into the Rx feature within the WCMSAP is one component used in CMS’s review, alongside review of the prescription payment history/pharmacy records and medical records.
- Redbook: CMS uses a feed from Redbook via Truven Health Analytics to calculate prescription drug pricing. Results display up to 500 entries and include the lowest-priced options that meet the criteria entered. Only drugs identified as active and available by a manufacturer are listed via the WCMSAP’s Redbook feed. Results will not include any discontinued or repackaged medications/National Drug Codes (NDCs) (WCMSAP User Manual Rev. 2015/5 January COBR-Q1-2015-V4.4, s. 11.5.1). See Figure 1.1 below for a sample view of the medication search function.
- Running total: After the user searches for each medication and selects the appropriate option, the WCMSAP populates a running total of the prescriptions entered for the submission with visibility into the name, dosage, frequency, and cost of the medication(s) selected. See Figure 1.2 below for an example.
- Changes to medication pricing: It’s possible that medication pricing will change before submission of a case in progress. This is most common if the user elects to begin a submission and leaves the case pending as a “work in progress” or uncompleted submission, having saved entries for prescription medications but not completing the submission and delivering the case to CMS for review. If that occurs, CMS will automatically update the drug prices and recalculate the totals for prescription medications at the time of submission (not at the time the medications were saved in the WCMSAP), based on the most current information in Redbook (WCMSAP User Manual Rev. 2015/5 January COBR-Q1-2015-V4.4, s. 11.5.4).
Impact on CMS Review
The efficiencies created with the WCMSAP in general have expedited CMS review times fairly significantly since its launch in late 2011. It appears that the prescription medication enhancement may have also improved review time, as average decisions are currently being returned within 30 days. That said, there are some issues to be aware of in the early days of using the portal’s prescription medication feature:
Items to watch:
- Inhalers, compound creams, and gels: These types of medications can be quite challenging to submit via the WCMSAP Rx feature because they are less straightforward in terms of frequency of use. Based on decision trending since the Rx enhancement went live in October 2014, and consistent with the disclaimer listed in the WCMSAP, it’s clear that CMS is looking at submitted material as a whole and not basing decisions strictly off data submitted in the WCMSAP. For example, if the prescription history shows that one inhaler is being used every three months, CMS is generally allocating four per year; it’s not possible for the user to indicate one-third inhaler per month in the WCMSAP, and accordingly, the user may enter “1” per month in the WCMSAP but not receive a counter-determination if it’s obvious from the pharmacy history or medical records provided that the claimant is actually using one inhaler every three months.
- Active ingredient: For certain medications, it appears that CMS is including the active ingredient in lieu of its brand name counterpart. For example, this is true of the medication Endocet. When submitting MSAs that include Endocet via the WCMSAP, the user is prompted to select the active ingredient — oxycodone-acetaminophen — versus brand Endocet. The price difference between brand Endocet and generic oxycodone-acetaminophen is $2.61 per pill (as of the time of this article), which can have a significant impact on the MSA.
- Portal vs. paper submission: It appears that CMS may be treating prescriptions differently depending on the means of submission. Specifically, ISO Claims Partners has found that CMS treated the above-referenced Endocet issue differently on a case submitted via disc. We’ve challenged the logic of this decision and are closely monitoring CMS’s response. In comparing cases containing Endocet via the WCMSAP, there was nothing obviously different from the case submitted via disc other than the means of submission.
- Frequency of use: It’s recently become apparent that CMS is allocating medications on a monthly basis versus a daily basis. While this may not be directly related to the Rx enhancement, it’s a trend that’s appeared since the launch of the prescription medication feature in the WCMSAP.
CMS has undertaken what appears to be a positive step toward more streamlined and efficient review of WCMSAs. Because the Rx feature is a new enhancement to the WCMSAP, ISO Claims Partners will continue to monitor submission modifications and decision data and provide updates on resulting trends. For more information on the WCMSAP or the CMS WCMSA process in general, Melissa Isaacs, director of Services, at email@example.com.
Melissa M. Isaacs is director of services for ISO Claims Partners. In her role, Melissa aids in overseeing preparation and submission of all WCMSAs. Melissa facilitates discussions with CMS regarding complex claims and escalated files and has built a strong relationship with both the Workers' Compensation Review Contractor (WCRC) for CMS and the CMS regional offices. Before her current role, Melissa comanaged the CMS Department, managed the Rated Age Department, and was an MSP compliance advisor with ISO Claims Partners. Melissa has also worked in WC claims processing and risk management for a major Boston-based hospital. Melissa is a member of the Massachusetts State Bar Association and can be reached at firstname.lastname@example.org or 978-825-6008.