Pursuant to Section 22.214.171.124 of the WCMSA Reference Guide, version 2.8, prescription medication pricing is based upon the Average Wholesale Price (AWP) of the drug with generic drugs being priced at the lowest non-repacked AWP rate. In accordance with WCMSA pricing guidelines, NuQuest submitted a WCMSA utilizing the lowest AWP price for a prescribed generic medication. CMS thereafter issued an approval letter increasing the price of the medication by approximately $17,000. After a critical review of the CMS determination by the NuQuest medical team, it was found that CMS did not follow the protocol outlined in Section 126.96.36.199 of the Guide and, instead, priced the generic medication at a much higher rate. NuQuest thereafter filed a Re-Review outlining the mistake in pricing. CMS agreed with the Re-Review and issued a new approval letter including our original pricing for the medication.
This case not only illustrates the importance of understanding WCMSA guidelines, but also the need to critically review CMS determinations to make sure these guidelines are followed. Failure to do so can result in increased WCMSA costs and missed opportunities for WCMSA reductions. NuQuest will continue to advocate for clients throughout the WCMSA process to help ensure CMS protocols are followed. Should you have any questions or need further information on our MSA services, please contact NuQuest at (866) 858-7161.
CMS seeks comment from industry professionals on options being considered for beneficiaries and their representatives to clarify how they can meet their obligations to protect Medicare’s interest in MSP Workers’ Comp or Liability claims. Comments must be submitted to CMS no later than 5 p.m. on August 14.
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NuQuest/Bridge Pointe (NQBP) and myMatrixx have teamed up to maximize MSA savings potential and minimize the risk of prolonged settlement negotiations!
This comprehensive solution identifies and optimizes opportunities to lower costs associated with both medical treatment and pharmacy utilization. The Pre-MSA with Drug Regimen Review (PMDR) combines a medical analysis and Drug Regimen Review to provide a unique and complete clinical evaluation of future injury-related drug and medical costs allowing you to control utilization and costs prior to CMS submission.
Since MSA guidelines, issued in June, 2009, indicated that CMS would independently price future prescription drug costs in Medicare Set-Asides (MSAs)— pharmacy utilization costs have increased significantly causing MSA settlement amounts to double or even triple— making it increasingly difficult to settle claims.
To minimize the risk of prolonged settlement negotiations and expedite case closures— while mitigating costs— NuQuest/Bridge Pointe has developed a unique approach which allows insurers to gain control of injury-related drug utilization, medical treatment and other high costs associated with a MSA— early in the process.
NuQuest/Bridge Pointe’s PMDR has realized a proven average savings of 72%— comprised of 84% savings in prescription drugs and 16% savings in medical treatment.
On April 3, 2012, Government Accountability Office (GAO) released a report – “Medicare Secondary Payer – Additional Steps are Needed to Improve Program Effectiveness for Non-Group Health Plans” – reflecting challenges, workloads, average MSA amounts approved, and more. The full report is available here.
A reminder regarding the proper address for submitting annual accounting documentation to CMS’ Medicare Secondary Payer Recovery Contractor (MSPRC).
Please send your completed annual Workers’ Compensation Medicare Set-aside Arrangement (WCMSA) Account Expenditure accounting documentation to the CMS lead Medicare Contractor at the address below:
MSPRC – Non-Group Health Plan (NGHP)
P.O. Box 138832
Oklahoma City, OK 73113