PMSI meets with CMS

Medicare Set-Aside Blog on October 1, 2010
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September 30, 2010
PMSI Meets with CMS Regarding Prescription Drug Allocation Issues
On September 20, 2010, PMSI Settlement Solutions met with Gerald Walters (Director, Financial Services) at the Centers for Medicare and Medicaid Services (CMS) to continue our dialogue around the pharmacy portion of Medicare Set-Aside (MSA) allocations. Our main focus during this meeting was to address inconsistencies we are all experiencing in the interpretation of the May 14, 2010 Memorandum regarding Part D covered prescription drugs. PMSI addressed inconsistencies concerning off-label prescription drug usage, the appropriate treatment duration for acute drugs, and the re-review process. For example, we highlighted inconsistencies across reviewers at the Workers’ Compensation Review Center (WCRC) regarding the exclusion of drugs like Lyrica, Gabapentin and Lidoderm. PMSI also requested that CMS issue a formal directive in regards to which compendia will be utilized during the review process. We highlighted the need for policies and procedures that would support the various policy memos.
CMS was extremely receptive to our feedback and willing to further investigate the issues facing the insurance industry surrounding drug allocations and the review process. CMS is considering retaining an independent consulting firm to help re-engineer the overall MSA review processes. The plan is for these consultants to meet with various industry participants to gain input into the process and challenges they face. We applauded this effort and offered any assistance which we could provide.
During our discussion, CMS mentioned that State fee schedules should be an acceptable means of pricing the pharmacy component—as long as the appropriate fee schedule is attached as back-up documentation. This would be a very welcome change and could give the industry some immediate relief. We hope to see a formal published announcement confirming this in the near future.
PMSI will continue to pursue these issues with CMS and will keep you updated.
For more information, please contact Otto Biasio, PMSI Settlement Solutions at or 303.730.2513.


Now this is something I can get behind. Marketing based on a substantive meeting where new information is being shared and solutions to our common problems are being addressed. Good job to PMSI for taking the iniative to meet with Gerald Walters and advancing some common sense solutions. I love the idea of actually pricing pharmacy at the state fee schedule or some other sensible alternative to AWP. And rather than releasing the compendia (based on our recent discussions with the WCRC they don’t even have a copy) why not just publish a list of common off-label drugs you will not consider? It probably will not reduce settlements drastically but it will take expensive medicines out of the WCMSA and allow for tapering and/or discontunation with appropriate supporting medical evidence.

Note to CMS – Rather than spending our hard earned tax dollars on a consultant(s) to revamp the WC review process, how about just asking the industry? We all know what is wrong and have the solutions to provide a quick, painless fix. Save the tax payers some money and get expert advice at the same time. What’s not to like about that?

My office is 15 minutes from yours. Call me anytime and let’s do lunch.