Cases & Points Blog

Client Realizes Half Million in Savings with NuQuest Re-Review

NuQuest strives to save our clients’ money, even years after the original settlement. One example is how a claim that was recently amended saved our client $567,706. Although the original CMS approval in January 2015 was for $780,736, a CMS Amended Review was requested by our client, due to a change in the treatment plan. Our updated review reduced the claim amount to $213,030, and the amended proposal was approved by CMS.

Our clients choose NuQuest as their trusted Medicare and MSP Compliance partner because we have a reputation for honesty and dependability. Over the years, we have assembled a core of specialists with industry-leading expertise in the areas of medicine, law and benefits. Contact us today to discover the NuQuest difference.

CMS Hosts Webinar on Medicare Secondary Payer Recovery Portal

On 8/16/2018 at 1:00 PM EDT, the Centers for Medicare and Medicaid Services (CMS) will be presenting an “Overview Webinar” on its Medicare Secondary Payer Recovery Portal (MSPRP). The MSPRP is a useful tool in assisting parties regarding the Benefits Coordination and Recovery Center (BCRC) and Commercial Repayment Center (CRC)’s collection of conditional payments. Click here to be directed to the notice.

Once BCRC has been notified of the settlement, judgment or award (TPOC), BCRC will generally issue Medicare’s final lien with respect to the claim’s settlement.

This process above should not be confused with the Commercial Repayment Center’s (CRC) separate collection for Ongoing Responsibility of Medical (ORM) reporting. CRC’s notice and initial determination process is not a final lien from Medicare. If ORM has been reported or terminated, CRC may issue a separate collection against the carrier or self-insured based upon the ORM reporting. In certain circumstances both companies CRC and BCRC may initiate collection over the life of the claim.

It is important to remember that, at this time, the MSPRP only provides information with respect to payments made under Medicare Part A and Part B.  There is yet to be a mechanism requiring CMS to advise its Part C and Part D partners that it has been notified of a TPOC or ORM reporting, legislators are trying to impact this issue through the Provide Accurate Information Directly Act, “PAID Act”, H.R. 5881.

A follow up will be posted after the 8/16/18 presentation.

SUCCESS STORY REGARDING A CMS COUNTER HIGHER APPROVAL

At NuQuest, we strive to remain a strong leader in the MSA industry. One way we do so is to closely monitor the CMS approval process and to bring to their attention any improper judgments. The case study below is an example of how NuQuest takes the time to bring errors to light, not only for our clients but for the entire industry.

The claimant sustained a right shoulder injury on Oct. 1, 2016, and underwent an arthroscopic rotator cuff repair on Apr. 27, 2017. On Aug. 11, 2017, the treating orthopedist noted that she was doing well and that she requested additional physical therapy. Her medications at the time included Tramadol 50mg every eight hours, as needed.  As a result of the follow-up visit, additional physical therapy was prescribed, and she was advised to follow up, as needed. No additional medications were prescribed.

A Panel Qualified Medical Evaluation (PQME) was completed on Dec. 17, 2017, and it noted that the claimant had not returned to the treating orthopedist. She was placed at maximum medical improvement with a 4% impairment rating. The PQME noted she was not a candidate for additional future medical treatment and should continue with a home exercise program.

In the absence of a pharmacy ledger, our MSA included Tramadol 50mg #90 per month for her life expectancy. As there was no indication of ongoing physician visits; we allocated two physician visits per year for her life expectancy as Tramadol is a Schedule IV drug. Prescriptions for Schedule IV controlled substances may be refilled up to five times in six months. Therefore, a new prescription is required every six months, which would need two physician visits per year. CMS increased the physician visits to four times per year with the only explanation being additional physician visits “are necessary.”

NuQuest requested a re-review based on a potential CMS error. Our re-review request advised CMS that physician visits are required twice a year when Tramadol is being prescribed, as it is a Schedule IV drug. Tramadol is not a Schedule II drug, the increase to four physician visits a year was an error by CMS. CMS completed the re-review and reduced the physician visits to two per year.

While the decreased MSA amount was not significant, NuQuest knows that it is important to advise CMS when an error is made. Otherwise, CMS would continue to increase physician visits to four per year when Tramadol is being utilized and no active treatment is being provided.

Effective Conditional Payment Negotiations Webinar – Join us on Wednesday, August 1st

Conditional payment collections can occur under various circumstances in non-group health plan claims and can leave parties bewildered regarding how and when an appeal can be filed. The audience will be provided with outline of appeal process and time frames, effective defenses and case studies of successful conditional payment negotiations with Medicare.

Register here to join us on Wednesday, August 1st at 3:00 PM (EST) with Patrick Czuprynski, Director of Lien Resolution.

UPDATE ON NEW WCRC CONTRACTOR’S REVIEW OF DIAGNOSTICS AND PHYSICAL THERAPY

Since the new WCRC contractor took over, we have seen an increase in the amount of diagnostics and physical therapy allocated by CMS resulting in many counter higher determinations. These counter higher amounts seem to be an increase between 5 to 10% of the submitted MSA amount.

Per the WCMSA Reference Guide, x-rays are allocated every 3 to 5 years and yearly if there was or will be a major joint replacement. MRIs are allocated every 5 to 7 years. CMS states these are guidelines only and determinations are made on a case-by-case basis. Other factors are considered such as the life expectancy, past surgeries, functional status, age of injury, treatment patterns, and provider recommendations. The trend we are now seeing is x-rays allocated every 3 years and MRIs allocated every 5 years regardless of these other factors. With the prior review contractor, these factors appeared to be taken into consideration as there were fewer counter higher determinations based on an increase in diagnostic services.

There are no physical therapy guidelines provided in the WCMSA Reference Guid, however, based on years of tracking CMS determinations, physical therapy (PT) is usually allocated at 12 sessions every 5 years for exacerbations. Additional physical therapy is also included post-operatively with the amount based on the type of surgery; 18 sessions for an arthroscopy; 36 sessions for a total knee replacement or total shoulder replacement; 24 sessions for cervical, thoracic or lumbar surgery; and 24 sessions for a total hip replacement. The prior review contractor seemed to take the type of injury and treatment patterns into consideration and accept the submitter’s allocation for PT if it was reasonable. The new review contractor appears to be increasing PT by allocating 12 sessions every 5 years for every orthopedic condition regardless of the type of injury and treatment patterns.

Here are a few example of CMS’ counter higher determinations based on increased diagnostics and/or PT.

Date of injury noted as 08/02/2012 for cumulative trauma with the following diagnoses: bilateral carpal tunnel syndrome, bilateral shoulder pain, bilateral knee pain, bilateral ankle/foot pain, cervicalgia, and low back pain. The life expectancy (LE) is 13 years. Future medical treatment included bilateral shoulder arthroscopies and bilateral ankle, right knee, and lumbar surgery. CMS included routine PT at 96 sessions for life expectancy; post-operative left shoulder PT at 18 sessions; post-operative right shoulder PT at 18 sessions; post-operative right knee PT at 18 sessions; post-operative right ankle PT at 18 sessions; post-operative left ankle PT at 18 sessions; and post-operative PT at 24 sessions for the lumbar surgery. X-rays were included every 3 years or a total of 4 in LE for the following body parts: cervical spine, bilateral shoulders, bilateral wrists, lumbar spine, bilateral knees, and bilateral ankles. MRIs were included every 5 years or a total of 2 in LE for all of these body parts except the wrists. The total amount of PT included in the allocation is 210 session in a 13 year LE. The submitted MSA amount was $93,483 and did not include the lumbar surgery per carrier’s request. The CMS counter higher determination was $180,217 as a result of the inclusion of the lumbar surgery and significant amount of diagnostics and PT.

Date of injury is 04/06/2007 for bilateral shoulder pain, bilateral knee pain, cervicalgia, and low back pain. LE is 19 years. Future medical treatment included bilateral knee arthroscopies, right shoulder arthroscopy, and lumbar decompression and fusion. 36 sessions of PT were included for exacerbations. Post-operative PT was included as follows: 24 sessions left knee arthroscopy; 24 sessions right knee arthroscopy; 24 sessions lumbar surgery; and 36 sessions for right shoulder arthroscopy. This is a total of 144 PT sessions for a 19 year LE. Submitted MSA amount was $246,941 with CMS counter higher amount of $269,957 due to increased PT.

Date of injury is 02/20/2015 for left shoulder pain, left wrist pain, left hand pain, left thumb sprain, left middle finger sprain, left ring finger sprain, left little finger sprain, and cervicalgia. LE is 12 years. Current treatment is medication management only with pain management.  24 sessions of PT were included for each of these body parts: left shoulder, left wrist, and cervical spine or a total of 72 sessions in LE. Submitted MSA amount was $21,106 with CMS counter higher amount of $28,578 due to increased PT.