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.

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