Industry 1 and CMS 0?

July 2014 – NuQuest participated in the Cold Water Challenge! Check out K:\ColdWater
to see our Kip Daniels drenched in freezing water, all for a good cause! Personally, I love
to see his surprised look when the cold water hits him.

July 2014, CMS released their “Crystal Ball” rationale – “reasonably probable and
predictable”. The rationale “reasonably probable and predictable” is used to justify the
inclusion of future services and Part D drugs that are no longer being utilized and/or have
not been prescribed for more than a year. An example is provided below.

The medical records (dated May 18, 2012 through March 20, 2014) and claim payment
history (dated August 6, 2014) provided to CMS were current at the time the WCMSA
was submitted to CMS on August 8, 2014. On March 20, 2014, the medical record
documented that the claimant was stable and was advised to follow up as needed. There
was no documentation of medication being prescribed or utilized. The pay history
confirmed there were no follow up visits beyond 3/20/2014 and documented the last
pharmacy date of service in 2010. CMS requested documentation from the claimant’s
personal physician and after many months; this was obtained and provided to CMS.
These unrelated medical records provided an extensive list of the claimant’s medications
and CMS determined that 2 of these medications were for the work injuries. CMS
therefore included hydrocodone/APAP and omeprazole in the Part D drug costs even
though these records did not document who was prescribing these medications or why
they were being prescribed. CMS noted that it was “reasonably probable and predictable”
that these medications would be continued through life expectancy for the work-related
condition.

Pharmacy continues to be a concern for the WC industry as a whole. In 2014, we have
grown increasingly concerned with the overprescribing epidemic and abuse resulting in death.

In another case where the claimant’s non-dominant hand was amputated, the medical
records and prosthetic evaluation noted the prosthesis would be cosmetic and not
functional. Even with these records, CMS included the hand prosthesis. Again, when a rereview
was requested based on this mistake, CMS would not change their opinion. And
in another case, CMS included shoe lifts. These would be covered only if they were being
prescribed for diabetic foot disease. The industrial conditions in this case were low back
pain and right knee pain. Therefore, shoe lifts would not be covered by Medicare in this
situation.

We continue to shake our head and ask where this is going….