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.

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