NuQuest’s Perseverance Pays Off

Our NuQuest team is always ready to seek a correction of an erroneous CMS determination.  A recent re-review victory is highlighted below.

Claimant filed two separate workers’ compensation claims against one employer that had two different workers’ compensation carriers for two different accident dates. Claimant sought treatment for both claims with the same treating physician. In an effort to separate the liability of the carriers and claimant for each claim, the treating physician noted in his records which medications belong to each claim. NuQuest submitted a WCMSA proposal that excluded a prescription projection based upon the medical records stating that certain prescriptions were being prescribed in relation to the separate claim and additionally, that an IMR determined that the medications were unreasonable and unnecessary. Medicare’s determination included a prescription allocation for the medication prescribed for the separate claim stating that because payments were made for the medications and there were no alternative treatment recommendation, the IMR was insufficient to remove the medications.

A re-review was submitted with the court award for the separate claim and an additional letter from the doctor that predated the WCMSA submission, again identifying which medications belong to each claim. After review, Medicare agreed that a prescription allocation was unnecessary because the medications belonged to a separate claim.

As indicated by this re-review, letters from prescribers will be sufficient to exclude medications from an MSA, in certain circumstances. Parties to a settlement should consider if the treating physician or prescriber will provide a written statement identifying exactly what is related to a claim.  This is good practice regardless of whether a proposed MSA is voluntarily submitted to CMS for review.

CWCI’s Report on Opioids in the WCMSA; where do we go from here?

The California Workers’ Compensation Institute (CWCI) is a private organization of insurers and self-insured employers that use claims data to identify problem areas in the workers’ compensation system and seek solutions for them within the industry. The CWCI recently put out a report entitled “Opioids in Workers’ Compensation Medicare Set-Asides” (WCMSA) based on the results of a study that examined the pharmaceutical component of approximately 8,000 CMS-approved WCMSA arrangements. The arrangements had been approved by CMS between January of 2015 and December of 2016.  NuQuest was one of the four national WCMSA vendors that provided data for this study.

Objectives of the Study

The study objectives included the identification of categories of the most frequent medications in the WCMSA study sample. Data from the CMS reviewed WCMSA arrangements was compared with data from a control group of 71,771 closed permanent disability claims from accident years 2006 through 2009  involving similar injuries without an associated WCMSA. Given the current opioid abuse epidemic, and CMS’ pharmacy projection model, it comes as no surprise that opioids were the most common drug group found in the WCMSAs that were examined. In addition, it is significant to note that the cumulative morphine milligram equivalents (MMEs) in the CMS reviewed WCMSAs were 45 times the amounts used in the control group.   Furthermore, pharmaceuticals accounted for only 17% of total medical dollars paid in the control group, while the pharmaceuticals in the CMS-approved WCMSA arrangements accounted for 47% of the total projected medical allocation.

The study also sought to determine whether CMS’ projection model for opioids aligned with evidence-based medicine guidelines for opioids. The American Pain Society, the American College of Physicians, and the American Academy of Neurology all recommend against the use of opioids for chronic pain since there is no evidence of improved function with the use of opioids for chronic low back pain (which accounted for 39% of the CMS-approved WCMSAs). Medical literature also indicates that individuals who are using benzodiazepines along with opioids are at an even greater risk of death. The CMS-approved WCMSAs, however, showed that 1 in 7 WCMSAs with opioids also included prescription allocations for benzodiazepines, while approximately 5 % of the WCMSAs with opioids had benzodiazepines and muscle relaxants. Although the authors of the study acknowledged that CMS reviewed WCMSAs estimate future injury-related care based on current treatment regimens, they cautioned that CMS’ presumption of the long-term use of opioids at these high levels places claimants at an increased risk of harm. The authors also called for modifications to the WCMSA projection methodology that would treat opioids differently than other medications as a matter of public policy.

So where do we go from here?

As one of the four national vendors that provided data for the CWCI report, NuQuest has been closely monitoring  CMS’ overfunding of determinations over the years. The need to address this resulted in our development of the non-submitted NuShield certified MSA. The certified MSA projects opioids and other care, in accordance with evidence-based medicine guidelines and the claimant’s current treatment regimen. The projections are both medically and legally defensible. In addition to our hold harmless and indemnification agreement that accompanies the NuShield certified MSA, our assistance in the administration of the certified MSA funds prevents premature exhaustion of the funds.

The use of the NuShield certified MSA in California cases and nationwide has resulted in significant pharmaceutical and medical savings. The table below illustrates the difference between the use of our evidence-based medicine pharmaceutical approach in California when compared with the use of CMS’ projection methodology for the same pharmaceuticals.

Rated Age Diagnosis NuShield RX using EBM CMS RX methodology
69 CRPS, pain LE, depression $38,822.00 $77,645.00
70 Status post fracture repair wrist, depression, insomnia, carpal tunnel repair $70,041.00 $181,728
55 Postlaminectomy syndrome, lumbar, cervicalgia, plantar fascitis $173,559.60 $253,303

The CWCI study’s comparison of pharmacy expenditures in its control group with the CMS pharmaceutical projections for a similar class underscores the disconnect between actual usage and CMS’ projection methodology. More information regarding the NuShield certified MSA program is available upon request by contacting Kip Daniels or Barbara Fairchild at or


Arizona and Medicaid Law Updates: Is Your Claim or Medicare Compliance Strategy Impacted? Join Patrick Czuprynski October 18th, at 2 PM (EST)

Changes in Arizona and Medicaid laws are in effect in October. Register here to join our one hour webinar that will discuss these changes and how they can impact your claim and Medicare compliance strategy. The audience will learn which claims can be affected by the new Arizona law and what options are available for compliance with the Medicare Secondary Payer Act. Further, the audience will understand the implications of Medicaid’s new rules with respect to the collection of payments.

New Mental Health and Substance Use Disorder Parity Rule for Medicaid announced by CMS

According to the National Survey on Drug Use and Health (NSDUH), there were approximately 43.6 million adults in the United States with mental Illness (18.2% percent of all U. S. adults) in 2014. 3.3 percent of all adults surveyed in 2014 had both a mental illness and a substance use disorder (SUD). “Illicit drug use” for purposes of defining an SUD, included the nonmedical use of prescription drugs without a valid prescription or use “simply for the experience or feeling the drugs caused.” (Center for Behavioral Health Statistics and Quality (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927 NSDUH Series H-50)).

In connection with the government’s push to halt the opioid epidemic, CMS issued a press release on March 29, 2016 that discussed the finalization of a rule that requires Medicaid and the Children’s Health Insurance Programs (CHIP) to provide greater coverage for mental health and substance use services. Prior to the October 3, 2009 implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), private health insurance plans generally provided less coverage for mental health conditions than for medical or surgical conditions. The MHPAEA changed that by mandating that group health plans and health insurance issuers treat mental health or substance use disorder benefits in the same manner as other medical/surgical benefits. CMS’ final rule that requires Medicaid and CHIP coverage for mental health and substance use services to be similar to coverage for medical and surgical benefits is long overdue. HHS Secretary Burwell stated: “Today’s rule eliminates a barrier to coverage for the millions of Americans who for too long faced a system that treated behavioral health as an unequal priority.” She further noted that “This rule will also increase access to evidence-based treatment to help more people get the help they need for their recovery and is critical in our comprehensive approach to addressing the serious opioid epidemic facing our nation.” (CMS News for Immediate Release, March 29, 2016)

CMS’ final rule provides states with flexibility in their delivery of services while ensuring that Medicaid enrollees requiring these services have access to them. CMS’ current opioid utilization initiatives signal a strong commitment to halting the opioid abuse epidemic facing our nation. We will continue to keep you advised of further developments.

Medicare Secondary Payer Issues and the False Claims Act

Medicare Secondary Payer (MSP) compliance is a specialized area that may be filled with traps for unwary attorneys, claimants and insurers. The traps may include a possible $1,000.00 a day penalty for failure to report a claim under Section 111 of the Medicare and Medicaid SCHIP Extension Act of 2007 (MMSEA), the threat of a double damages action by the U.S. Attorney’s Office for failure to reimburse Medicare’s conditional payments in a settlement as well as the threat of a private cause of action by a provider, Medicare Advantage Plan or a non-group health plan. Last, but not least, is the potential exposure for failure to reimburse Medicare’s conditional payments under the False Claims Act. This blog will examine MSP recovery in the context of the False Claims Act.

Under the False Claims Act (FCA), 31 U.S. Code Sections 3729, it is unlawful for any person to “knowingly make, use or cause to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government or knowingly conceal, or knowingly and improperly avoid or decrease an obligation to pay or transmit money or property to the Government.” The civil penalty associated with this is “not less than $5,000 and not more than $10,000 ….plus 3 times the amount of damages which the Government sustains because of the act of that person.” The FCA is intended to prevent fraud against the government. Since private individuals are often in the best position to detect this fraud, the FCA allows private individuals to bring the civil action for the person and for the US Government. These actions are known as qui tam lawsuits. If the Government proceeds with the action brought by the private individual, the “whistleblower” shall receive at least 15 percent but not more than 25 percent of the proceeds of the action or settlement, depending upon the extent to which the person substantially contributed to the prosecution of the action. (31 U.S. Code Section 3730(b) (d)). Although this financial incentive is necessary to help offset the hardship associated with such an action, it may also result in the pursuit of frivolous claims.

The case of United States of America, ex rel J. Michael Hayes, v. Allstate Insurance Company, et al 1:12-cv-01015 S, USDC WD NY (2014) provides one such example of a frivolous claim. In Hayes, the Relator, a plaintiff’s attorney, claimed that various insurance companies were shifting their obligations to reimburse the Medicare Trust Fund for conditional payments by using general boilerplate release language in settlement documents. This alleged shifting of the obligation was an action designed to “improperly avoid or decrease an obligation” under the FCA. Although an interesting theory, the merits of the argument were not addressed since the amended complaint was dismissed by the U. S. District Court with prejudice on February 8, 2016. Hayes’ failure to provide support for his “disproven allegations that he had personal knowledge that all defendants were engaged in a nationwide scheme to defraud the United States by failing to reimburse Medicare whenever they settled liability claims with a Medicare beneficiary” despite numerous “safe-harbor opportunities” showed a violation of Rule 11 of the Federal Rules of Civil Procedure. Rule 11 requires that the pleadings presented to the court contain factual contentions with evidentiary support. In the Hayes claim, it was clear to the court that Hayes lacked any such personal knowledge.

A similar abuse of the FCA is seen in the case of United States of America, ex rel Kent Takemoto vs The Hartford Financial Group, et al 11-CV-613S, USDC WD NY . In this claim, the Relator, Dr. Kent Takemoto, an MSP vendor executive, claimed that various liability insurance carriers and other companies, refused to meet their MSP obligations since they declined his company’s MSP compliance services. The services included Medicare Set Asides as well as conditional payment searches and negotiations. This case was dismissed with prejudice on January 20, 2016 finding that Takemoto’s amended complaint failed to allege plausible causes of action.

On the other hand, the case of United States of America ex rel. Saint Joseph’s Hospital Inc, and ex rel Candler Hospital, Inc v United Distributors, Inc et al, CV410-096, USDC, S.D Georgia, Savannah Division, survived a defense motion for summary judgment on December 7, 2015. This case involved a qui tam action brought under the FCA by two hospitals for Medicare fraud due to an alleged false COBRA election for the Defendant United Distributor’s employee, W.A. The Government intervened in this action and subsequently filed its own complaint.

By way of background, W.A. claimed a work injury on March 12, 2008 when he lost consciousness, fell and hit his head. After the accident, W.A was taken to the emergency room at Candler Hospital and then transferred to St. Joseph’s Hospital where he eventually had brain surgery. After the surgery, W.A developed an unrelated colon rupture which was surgically repaired. W.A. died from post-operative complications on May 27, 2008.

Upon receipt of notice of the workers’ compensation claim, W.A.’s employer, Defendant United submitted claims for his medical care through its workman’s compensation program. The workman’s compensation program however denied the claim. Subsequent discussions with W.A.’s wife allegedly centered on various medical bill payment options given the denial of the workman’s compensation claim. W.A.’s wife’s election for COBRA continuation coverage is the subject of this dispute with St. Joseph’s and Candler Hospitals and the Government claiming that the alleged COBRA election was falsified by the Defendants in order to avoid covering W.A.’s medical bills as the primary payer.

In refusing to grant the Defendants’ motion for summary judgment, the Court noted that there was sufficient evidence for a reasonable jury to find that a claim had been established under the FCA. The case was referred to be set for trial. It also serves as an example of an appropriate use of the FCA in the area of MSP recovery.

Attorneys, claimants and insurers may protect themselves from claims under the FCA by performing a comprehensive MSP compliance analysis of each claim. Key factors to consider include a review of the future injury related Medicare covered treatment needs in a claim that will close out medical as a term of the settlement as well as the obligation to reimburse the Medicare Trust Fund for any conditional payments made in the claim. Certain settlements should contain a future medical allocation in order to prevent a cost shift of future injury related care to Medicare. We also recommend specific provisions that detail the manner in which conditional payments will be reimbursed to the Medicare Trust Fund. Settlement discussions should also include the parties’ obligations in regards to reimbursement/ negotiation of injury related payments made by a Medicare Advantage Plan. Section 111 reporting under the MMSEA should be accurate and complete, without the omission of any disputed ICD9 or 10 codes. Although navigating the area of MSP compliance may at times seem daunting, it is an area that should be addressed in connection with your workers’ compensation and liability claims. We will keep you advised of further developments.