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May 2016 Newsletter
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NAMSAP Quarterly Newsletter 
Volume 9, Number 2
          May 2016
Press Release
Elmhurst, IL
March 23, 2016:  

National attention is finally being paid to the opioid epidemic in the United States, as we experience the catastrophic impact of the robust marketing of those drugs on Americans for treating chronic, non-malignant diagnoses such as back pain and arthritis since the 1990's. The National Alliance of Medicare Set-Aside Professionals (NAMSAP) is leading the charge on limiting opioid usage by requesting that the Centers for Medicare and Medicaid Services (CMS) cap costs earmarked for future opioid expenditures, thereby seeking to reduce ongoing usage of these dangerous medications.
 
According to the January 1, 2016 Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report, approximately 47,000 deaths in 2014 were related to overdoses from opioid pain relievers and heroin[1]. This figure represents a 6.5 percent increase from the opioid overdose deaths reported in 2013. In an effort to address this issue, the Food and Drug Administration (FDA) re-classified opioids as Schedule II drugs. President Obama also highlighted the problem in the opening minutes of his State of the Union address to Congress this year. Rather than relying solely on physicians to rectify the problem, most states are taking legislative action to counteract the life-threatening effects of opioid abuse, by taking proactive steps to place caps on and limit the prescription of opioids for chronic benign pain altogether. According to a recent article in the New York Times, there are currently about 375 proposals in state legislatures to regulate pain clinics and aspects of painkiller prescriptions[2]. In addition, criminal charges are finally being brought against medical providers who repeatedly ignore the science and prescribe lethal doses of opioids. Despite all this attention, opioid over-prescription, addiction, overdose and death continue to ravage our population.
 
Evidence-based studies have long shown that long-term use of opioid medications for chronic, non-cancer pain is ineffective, counterproductive and, if left unchecked, deadly. 90% of chronic pain is not effectively treated with opioids, and opioid use for chronic pain is not associated with any increase in function. Using opioids for more than seven days doubles the risk of disability at one year. Every patient who is chronically prescribed opioids will develop dependence, and 60%  of those prescribed opioids for more than three months, will still be on opioids in five years[3] [4]. Knowing this, shouldn't the workers' compensation industry, WCMSA vendors and CMS work together to be a part of a solution to this epidemic, rather than promote it?
 
Medicare Set-Asides (MSA) are meant to ensure that settlements do not inappropriately shift the burden of injury-related, future medical expenses to the Medicare system. Medicare only has an interest in post-settlement items that are both compensable under state law and covered by Medicare. CMS' own opioid overutilization policy recommends Part D sponsors lower their safety edits to set red flags for beneficiaries taking a 120mg MED daily dose for more than 90 days and with prescriptions from more than three prescribers/pharmacies. Stricter limits are currently being re-examined by CMS in its 2017 Draft Call Letter to further reduce unsafe overutilization of opioids. Patients aged 65 and over, Medicare's largest population, are more susceptible to accumulation of opioids, cognitive impairment, respiratory depression and overdose[5]. So why do WCMSA approvals often include future prescription allocations with Morphine Equivalent Dosages in excess of 120, 200 or even 500 per day, over the beneficiary's full life expectancy?  And what message does a WCMSA supporting these high opioid dosages over a patient's entire life expectancy send to the addicted patient?
 
Medical literature shows a 12 time increased risk for death from overdose when taking more than 40mg MED per day[6]. Absent solid science to support the use of these drugs, continuation is unjustified.
 
NAMSAP is confident that by working together with CMS to combat excessive opioid allocations in WCMSA's, patient safety will be enhanced.In order to facilitate this, NAMSAP supports the following:
  1. A hard cap of 90 MED based on CDC guidelines for no more than one month when the WCMSA includes a surgical projection; and/or,
  2. A hard cap of 40 MED for no more than one month, followed by a 10% per week mandatory tapering and weaning plan, as recommended by the CDC, until fully weaned from opioids[7].
The National Alliance of Medicare Set-Aside Professionals (NAMSAP) is the only non-profit association exclusively addressing the issues and challenges of the Medicare Secondary Payer Statute and its impact on workers' compensation and liability settlements. Through the voluntary efforts of our members, NAMSAP is a forum for the exchange of ideas and is a leading resource for information and news in this constantly evolving area of practice. The collective knowledge of our members and NAMSAP's resources will provide attorneys, nurses, settlement planners, claims professionals, and others with the ingredients essential to their success.


[1] "Increases in Drug and Opioid Overdose Deaths - United States, 2000-2014." Morbidity and Mortality Weekly Reports (MMWR). Centers for Disease Control and Prevention (CDC). January 1, 2016. Accessed at: http://goo.gl/3cicJ7.
[2] "States Move to Control How Painkillers Are Prescribed." B. Meier & S. Tavernise. The New York Times. March 11, 2016. Accessed at: http://goo.gl/kucKZj.
[3] "Safely Prescribing Opioids in Practice." G. Franklin. American Academy of Neurology (AAN). Course C171-Opioids and Marijuana in Your Practice. April 19, 2015. Accessed at: http://goo.gl/KD3E6W.
[4]"Long-Term Chronic Opioid Therapy Discontinuation Rates from the TROUP Study." B. C. Martin, et al. Journal of General Internal Medicine. (12):1450-7. December 2011. Accessed at: http://goo.gl/fGb9Xk.
[5] "Management of Opioid Analgesic Overdose." E. W. Boyer. New England Journal of Medicine. 367(2): 146-155. July 12, 2012. Accessed at: http://goo.gl/9LuIk1.
[6] "A history of being prescribed controlled substances and risk of drug overdose death." L. J. Paulozzi, et al. Pain Medicine. 13(1):87-95. January 2012. Accessed at: http://goo.gl/8mUbtL.
[7] "CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016" D. Dowell, et al. Morbidity and Mortality Weekly Reports (MMWR). Centers for Disease Control and Prevention (CDC). March 18, 2016. Accessed at: http://goo.gl/4SaS17.


By: Gary Patureau, CWCP, CMSP
Executive Director/COO  Louisiana Association of Self-Insured Employers (LASIE)

NAMSAP Members:
 
I would like to thank all that have renewed their membership for 2016 and would like to encourage those that have not yet renewed for 2016 to do so asap. For all those that are reading the NAMSAP Advisor for the first time and are not a member, I would like to say welcome and urge you to join NAMSAP.

The Board of Directors, Advisory Council and committee members are working to rebrand and strategically revitalize NAMSAP as an organization. We have been very active this year in all areas. One of our main goals is to get our members to join us by rolling up their shirtsleeves. We are encouraging our members to join individual committees.
  • We have created a new Liability MSP Committee chaired by Josh Pettingill of Synergy Settlement Services. They are in the process of developing an action plan for the committee that will soon be providing critical information to members in the liability arena.
  • The Conference Committee co-chaired by Michelle Allen of Burns, White has developed an outstanding agenda for this year’s conference and just wait till you see the speakers – incredible. This year’s conference is a must attend for all in the industry. Not only will you learn the latest regarding MSP compliance, you will meet and network with the who’s who of the industry. Did I mention that we guarantee you will also have fun? Did I mention that this is the most cost-effective conference / CLASS focusing on MSP issues?
  • The EBM Committee co-chaired by Amy Bilton of Nylan Bambrick Kinzie & Lowry has just recently released a policy statement calling for a cap on opioids in the MSA. NAMSAP is the first organization calling for clarity in what should be considered evidence-based medicine / prescribing in the best interests of the beneficiary. The Committee will also host Part II & III in the webinar series “Opioids in the Life of the MSA” in June and August. The committee’s call-to-action will be industry changing.
  • The Webinar Committee chaired by Shawn Deane of ISO Claims Partners has scheduled seven webinars this year. We just concluded the second webinar “Blurred Lines: Where Life Care Plans and MSA’s Intersect”. We would like to thank Shirley Daugherty and Shelene Giles from American Association of Nurse Life Care Planners (AANLC P) for instructing. Please see the website www.namsap.org for the upcoming schedule.
  • The Legislative and Case Law Committee co-chaired by Erin Collins of Hedrick Gardner Kincheloe & Garofalo and Katie Fox of Franco Signor have surveyed the membership and ranked the legislative and regulatory issues that are most important to our members. They are crafting next steps in reaching out to members of Congress and CMS.
  • The Data & Development Committee chaired by Fran Provenzano of Medicare Set-Aside Specialists is steadily gathering a variety of data on everything from submitted MSA’s to tracking new medications.
  • The Membership Committee co-chaired by Emily Grocoff of Medivest Allocation Services and Michelle Allan of Burns White are fine-tuning benefits received by Professional and Partner members. They are encouraging companies with multiple members to consider joining at the Partner level to save money and increase benefits. They have also targeted companies in the industry that they hope will consider membership. Look for new member benefits for all.
  • The MSCC Sub-Committee chaired by Leslie Schumacher of Planpoint and Fran Provenzano of Medicare Set-Aside Specialists are working to update the NAMSAP MSCC training modules. The modules will be ready in June. We are excited to also be administering the practicum component and will proctor the MSCC test at our annual conference and scheduled regional meetings.
  • The Communications Committee chaired by Rita Wilson of Tower MSA Partners is leading the rebranding efforts and assisting each committee in developing its marketing strategy. Our NAMSAP newsletter has been reformatted and renamed the “NAMSAP Advisor”. Rita and her committee have also suggested updates for the website and social media platforms. One of the goals of the committee is to help NAMSAP better communicate its message.
I would like to thank the chairs and each member of the committees for the time they are giving to help NAMSAP be responsive to our members and more influential in the MSP world. My hats off to the NAMSAP staff, our Executive Director Brian Bailey, Meeting Planner Kerri Leonard, Membership Coordinator Lisa Kennelly, Marketing Communications Coordinator Jackie Peiffer and our Accountant Sarah White.

Don’t forget to take advantage of the Early-Bird Registration for our “Remember the AlamoLLocation” Annual Conference in San Antonio. It will be one of our best!
 
By:
Robert L Sagrillo, JD, LLM
      President and Chief Legal Officer, 

As Medicare Secondary Payer (MSP) consultants, we tend to be contacted by clients about other public benefit issues that arise during the claim resolution process. Lately, it seems that Medicaid is the hot topic. Concerns include reporting obligations and lien resolution. This article provides high-level background on both of these concerns to enable the parties to spot issues in a given claim. Of course, once the issues are spotted, a resource will need to be identified to aid in resolution.
 
Reporting Obligations
 
As of yet, there is not a Federal reporting obligation (like Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007) relative to Medicaid beneficiaries. Since Medicaid is a program governed by both the Federal government and the states, however, there may be a reporting requirement in the state where a given claim is being resolved. These requirements generally take two forms: data exchanges and intercepts.
 
Data exchanges are computer processes that match Social Security Numbers of public assistance recipients (or other data points) against Federal databases and participating States. One of the most widely used programs is the Public Assistance Reporting Information System (PARIS). The main objective of PARIS is program integrity and to provide states a tool for potential fraud detection. PARIS primarily matches five programs: TANF, Medicaid, Food Stamps, Child Care, and workers' compensation. Currently, 44 states participate in PARIS, many of which are considering adding workers' compensation to their PARIS match. Once a state adds their workers' compensation data to PARIS, it will be able to: identify workers claiming benefits in more than one jurisdiction; coordinate primary payment obligations; identify claimants who have moved out of state; identify claimants committing fraud; and potentially aid in lien recovery.
 
The other Medicaid reporting requirement that is being adopted or considered by some states is a Medicaid intercept. A Medicaid intercept program electronically matches state Medicaid recipients with liability and workers' compensation insurance claims so as to intercept payments to claimants for reimbursement to a state's Medicaid program. Rhode Island was the first to adopt such a program and several other states are considering similar programs. In fact, the National Conference of Insurance Legislators (NCOIL) has drafted a Proposed Model Act Regarding Medicaid Interception of Insurance Payments that may serve as a template for those states interested such a program.
 
Lien Resolution
 
Federal law requires that states try to recover Medicaid costs by imposing liens on property sold by Medicaid patients and by claiming refunds from the estates of deceased Medicaid recipients. Such estate claims must be imposed by Medicaid for costs of nursing facility services and certain related services, and claims may be imposed by Medicaid for costs of other services. Each state has adopted variations of this Federal estate recovery requirement.
 
Furthermore, whenever a Medicaid recipient receives medical assistance for an injury or condition for which a third party is liable, Medicaid has an enforceable right against that third party to recover the amount of the medical assistance paid by the State. Medicaid lien statutes vary from state to state. In most states, Medicaid has an interest in any action that the Medicaid recipient has brought, or may bring, to determine the third party's liability. Consequently, even if the Medicaid recipient's attorney only sends a letter to the liable party, the state typically has an interest in that claim. Generally, a complaint or petition does not have to be filed.
 
In a majority of states, whenever Medicaid has furnished medical assistance for an injury or condition for which a third party is liable, the state has an automatic statutory lien for all medical assistance furnished to the Medicaid recipient. The Medicaid lien is against the judgment amount, award or settlement in a claim or suit against the third party. In some states, the lien may be reduced to cover the attorney fees and costs of the plaintiff in procuring the judgment, award, or settlement. Generally, this reduction will not be applied if the State had to intervene in the proceedings.
 
Most state laws are drafted so that when this lien exists, no judgment, award or settlement amount in any action or claim to recover the Medicaid recipient's damages for injuries can be satisfied without first satisfying the lien.
 
Because the federal government provides approximately 50% of Medicaid funding, CMS has a great deal of control over state Medicaid programs - particularly when a state waives or compromises its Medicaid lien. CMS has recently warned states that they should have good cause for waiving or reducing Medicaid liens. These warnings are generally taken seriously, as CMS has been known to sue states for being too generous with lien waivers and reductions.
 
Apportionment
 
Another issue with respect to Medicaid liens is that of reduction by apportionment. The Medicaid Secondary Payer statute, 42 U.S.C. 1396a(a)(25), provides that Medicaid is the secondary payer for a Medicaid beneficiary's medical costs. Like the MSP, any primary payer with responsibility for a Medicaid beneficiary's medical expenses must pay before Medicaid, which includes proceeds of a settlement or judgment.
 
Currently, Medicaid's lien recovery is limited to that portion of a settlement or judgment that is for health care items or services. Medicaid may not assert its lien against other aspects of the underlying claim, e.g. lost wages and other nonmedical damages. As a result, settlement or judgment proceeds may be allocated among the various damage elements asserted in an underlying claim based on their relative value. In the near future, however, this may change and Medicaid's lien may be asserted against all amounts paid to a claimant regardless of the character.
 
Section 202(b) of the Bipartisan Budget Act of 2013 removes the Medicaid statute's reference to "payment by any other party for such health care items or services" and substitutes the phrase "any payments by such third party." The result of this statutory amendment is that Medicaid liens will be recoverable from any payments by a third party. Fortunately, the effective date of this amendment has been pushed off twice. Most recently, the Medicare Access and  CHIP Reauthorization Act of 2015 delayed the effective date to October of 2017.
 
Adding Value
 
While not all MSP consultants are Medicaid experts, we can certainly identify issues that our clients need to further investigate. Doing so will add value to the services we provide and likely ingratiate us to our clients by helping to bring claims to resolution. Medicare and Medicaid are worlds apart, but they're not so far that we can't recognize opportunities where we can be part of the solution.

 

By:  Steven J. Miller, M.S.Pham. D. Ph., R. Ph.
       President, Clinical Services,  

The Medicare STARS ratings system began in 2007 as a way for CMS and Medicare beneficiaries to assess Medicare Advantage (MA) health plans. The introduction of a 5-star quality rating system by the Affordable Care Act (ACA) has brought some big changes to the MA market, including market consolidation and movement towards higher quality offerings in the marketplace by the remaining plans.  

Because it routinely receives recommendations and suggestions for continuous quality improvement, CMS tends to make updates to the quality measures for the STARS program from year to year as the program evolves. Clinical quality is a major focus of CMS, working with healthcare groups throughout the country covering a wide swath of the clinical landscape using some of the mounds of data required by the ACA for participating health plans.  
 
One such group is the Pharmacy Quality Alliance (PQA). It was established in 2006, and its mission is "..to improve the quality of medication management and use across healthcare settings with the goal of improving patients' health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality." http://pqaalliance.org/about/default.asp.
 
With ACA Act provisions dictating payment incentives for better overall performance, there is now a financial reward for understanding how the ratings work and using this to drive improvement. This motivates plans to be more adherent to the provisions. Therefore the performance measures adopted by CMS for the Medicare STARS program will weigh heavily on decisions made by plans and providers for long term treatment protocols.  
 
MSAs take into account long term usage treatment plans; they must account for prescription drug usage for the life expectancy of the patient based on appropriate life tables, unless a drug is noted as not covered by Medicare in official CMS guidelines.
 
For many injured workers pain is a condition that results in life long treatment. However, as a result of changes in prescribing patterns of opioids in the last 10-15 years, morbidity and mortality have increased in patients prescribed high daily doses of opioids (ie, 100 to 120 mg/day morphine-equivalent doses [MED]).
http://www.jabfm.org/content/26/4/394.full.pdf
 
As a result, the PQA has endorsed three measures concerning opioid use in the area of patient safety. They all examine multi-provider, high dosage opioid use among individuals 18 years of age and older without cancer and not in hospice:
  1. The proportion (XX out of 1,000) of individuals without cancer or hospice receiving prescriptions for opioids with a daily dosage greater than 120 mg morphine equivalent dose (MED) for 90 consecutive days or longer.
  2. Measure 2 (Multiple Prescribers and Multiple Pharmacies): The proportion (XX out of 1,000) of individuals without cancer or hospice receiving prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies.
  3. Measure 3 (Multi-Provider, High Dosage): The proportion (XX out of 1,000) of individuals without cancer or hospice receiving prescriptions for opioids with a daily dosage greater than 120 mg morphine equivalent dose (MED) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies. (497)
 
The XX in the standard represents what the final proportion of patients will be that will represent a failure of the standard. This will be determined following the receipt of responses from commenters to this standard.www.cms.gov/medicare/healthplans/medicareadvtgspecratestats/downloads/announcement2017.pdf.
The National Committee on Quality Assurance (NCQA) is adapting the three opioid overuse measures developed by the PQA for potential use in HEDIS. This will add further credence to the measures, when they can be applied to an MSA.
 
In an effort to assess the quality of pain management and treatment, and if necessary to reduce the utilization of pain medications, NCQA is exploring opportunities to developing new measures that will be based on appropriate pain management.
 
CMS is proposing in their 2017 program enhancement document, the 2017 Call letter, the following:
  1. a soft opioid edit threshold should be set at levels no lower than 90 mg MED, and
  2. a hard opioid edit threshold should set no lower than 200 mg MED expectations for Part D plans to implement these edits to prevent opioid overutilization at point of sale.
CMS expects, in calendar year 2017, that the P & T committees will develop the specifications based on this information for their formulary-level cumulative MED point-of-sale edit(s) based on the opioid over-utilization in their Part D plans, and reasonable numbers of targeted beneficiaries for plan oversight.
 
By adopting these measures, CMS has shown its' commitment to addressing the growing opioid problem, one that many refer to as an epidemic. CMS has reported the success of  the Part D Overutilization Monitoring System in lowering the number of Part D beneficiaries identified as potential opioid overutilizers. https://www.cms.gov/Medicare/Prescription-Drug-coverage/PrescriptionDrugCovContra/RxUtilization.html

This success can certainly be referenced when building an MSA that must include pain medications. Government proposals for both maximum quantity per prescription and over a length of time are listed, and should be able to be used when structuring an MSA at a clinically defensible level


By:
Heather  Schwartz Sanderson, Esq., MSCC, CHPE, CLMP, CMSP
 
    Chief Legal Officer
The False Claims Act's (FCA) purpose is to deter fraud upon the U.S. government, and whistleblowers are incentivized to bring such actions due to the potential to recover triple damages against the fraudulent entity. With regard to Medicare Secondary Payer (MSP) FCA litigation, we have really only seen two whistleblowers try to bring MSP FCA actions up until now, United States of America ex. rel. Dr. Kent Takemoto v. ACE et al. and United States, ex. rel. J. Michael Hayes v. Allstate Insurance Company, et al. As of just last month, January 2016, both Takemoto and Hayes' actions were dismissed in the Western District of New York for failure to plead specificity in their claims. Only the United States is able to re-assert these actions, which it is unlikely to do, since it didn't intervene in the suit initially.
 
For a short time, we were able to breathe a sigh of relief with no known MSP FCA litigation in sight. But now, we have new MSP False Claims Act litigation that we need to keep an eye on, as the result of this litigation can have meaningful impact and precedent on future whistleblower MSP FCA claims against auto/no-fault insurers and even workers' compensation. The new litigation is Negron v. Progressive, 2016 U.S. Dist. LEXIS 24494 (March 1, 2016), and it arises out of the United States District Court for the District of New Jersey.
 
In Negron, the whistleblower/relator is Elizabeth Negron ("Relator") and she alleges that Defendants Progressive Casualty Insurance Company and Progressive Garden State Insurance Company ("Defendants") violated both the Federal FCA as well as New Jersey's FCA by allowing Medicare and Medicaid beneficiaries to elect a "health first" automobile insurance policy through an online application, which caused health care providers to submit claims to Medicare and Medicaid in violation of secondary payer laws. Defendants filed a Motion to Dismiss Relator's claims and the NJ District Court denied the Motion to Dismiss.
 
The NJ District Court's looked at several factors when deciding to deny the Motion to Dismiss. Under New Jersey's law relating to automobile insurance, policyholders have the option of utilizing their personal health insurance as the primary payer of medical bills resulting from a car accident. However, the regulation specifically excludes recipients of Medicare and Medicaid from this option; therefore, NJ's law is consistent with both Medicare and Medicaid secondary payer laws.
 
When Relator purchased a policy online with Progressive.com back in 2009, at the time she had the option to select either a "health first" policy or a Personal Injury Protection (PIP) plan. When utilizing Progressive's online application, the website did not direct Relator to choose a PIP plan so that her auto insurance would be primary to Medicare, but rather it allowed her to choose a health first policy despite her Medicare coverage (it did not question Relator as to her type of personal health insurance). To ensure that Medicare would not become a primary payer, the website should have directed her to choose a PIP plan through Progressive, but it did not. Additionally, when Relator's healthcare providers submitted medical bills to Progressive, it sent denial letters to the providers instructing them to instead submit her health care bills to her primary health insurer, which for the Relator was Medicare. Medicare denied one of her bills as untimely but conditionally paid for some of her bills which was later reimbursed by Progressive.
 
To state a claim under the FCA, a plaintiff must demonstrate that: 1) the defendant presented or caused to be presented to an agent of the United States a claim for payment, 2) the claim was false or fraudulent; and 3) the defendant knew the claim was false or fraudulent.
 
The Defendants here asserted that Relator had not proved two of the three prongs of the FCA claim: that the claims submitted were false or fraudulent and were submitted knowingly. The NJ District Court disagreed and found that by Progressive remaining ignorant of the fact that Relator did not have qualifying health insurance (i.e. a non-Medicare/Medicaid health insurance policy) for a health first policy, Progressive in fact caused Realtor's health providers to treat Medicare as the primary payer of Relator's auto-related medical costs. Furthermore, Medicare never was, nor by law could it ever be, a primary payer given the existence of Relator's no-fault policy. Stated differently, Defendants caused Realtor's health providers to submit bills to Medicare that Medicare could never be responsible for on a permanent basis.
 
Furthermore, Progressive had sufficient time and ability to prevent Relator from purchasing a health first policy in the first place and could have questioned the type of personal health insurance she had so as to have avoided providing a health first policy to a Medicare recipient. Additionally, while the NJ District Court agreed that Relator had not pointed to explicit language in MSP which states, "auto insurers must prevent persons insured by Medicare from enrolling in health first policies which cause Medicare to act as the primary payer," the fact that such events apparently occurred, and apparently so easily, would have the effect if proven of subverting the entire Medicare Secondary Payer statutory scheme envisioned by Congress.
 
Further discussion was had by the NJ District Court as to Medicare's ability to pay conditionally. While all parties were in agreement that under the MSP Medicare may pay conditionally subject to reimbursement by the primary payer, the NJ District Court held tight to the fact that the intent behind the MSP is to prevent Medicare from paying where a primary payer exists, such as an automobile insurance policy. Specifically, the NJ District Court noted: "It makes no sense, adds unnecessary costs, and increases the risk of administrative failure, for the claims process to figure that out at the end rather than the beginning. Simply put, the Defendants are asking the Court to ignore the forest for the trees."
 
This litigation has significant implications for auto/no-fault insurance carriers and even workers' compensation. If this action is successful, it will create precedent that insurers have the responsibility under the MSP 1) To ensure that Medicare beneficiaries do not enroll in plans where Medicare can be designated as the primary payer, and 2) To proactively identify Medicare beneficiaries so as to ensure that Medicare does not pay conditionally- in other words, Medicare should not have to "pay and chase." I will continue to monitor this litigation and in the meantime strongly recommend carriers have a proactive strategy in place to avoid Medicare paying as a primary payer, despite the ability to reimburse Medicare for these condition.


NAMSAP Committee News
Evidence Based Medicine (EBM) Committee
The Evidence Based Medicine (EBM) Committee recently put together a statement that outlines NAMSAP’s proposed evidence- based limits on opioids in MSAs. The statement was released to the press on March 23, 2016.

Given the recent increased attention to the national opioid epidemic in the United States and the ever growing body of medical literature regarding the dangers of long term use of opioids for chronic non –malignant pain, the EBM Committee is cautiously optimistic that CMS will cooperate with our call for hard caps on excessive Morphine Equivalent Doses (MED) in MSA projections. Although CMS’ projections have historically been based on treatment and pharmacy patterns in every case, the national push for a transformation in the way opioids are prescribed, coupled with wide legislative proposals for action and criminal prosecutions, set the stage for CMS’ development of an evidence based hard cap limit on opioids. 

The EMB Committee has also resumed work on Part II and Part III of the “Opioids in the Life of the MSA” webinar series. Part II of the series will address current CMS policy and its application, while Part III will address our call to action.

We will continue to keep you advised of further developments. 


The Education Committee has been working tirelessly to deliver the biggest and best Annual Conference we have ever had. The Committee has been meeting and brainstorming for months. The topics are developed and top flight speakers have been confirmed for many.

Webinars will be a key part of our 2016 offerings and the number of Webinars has been increased to not only improve our membership knowledge base but to also afford more opportunities for Continuing Education credits.

We are working on the ongoing development of our MSCC programs as well on training modules.


Data & Development (DDC) Committee

During our April 20, 2016 conference call, the DDC committee members identified some rather small, however impacting changes currently seen with generic medication pricing along with issues of inclusion or exclusion of Zofran in chronic pain situations within a CMS approval. Several members spoke of IMRs as supporting documentation working well with an exclusion of medications within a submission.

Re-reviews were discussed along with suggestions from committee members on how best to approach these situations. The Georgia 400 week limitation cap was addressed. Lastly, there appears to be a trending with approvals of a 6-7% counter-higher rather than what we had seen at a 5%.

We welcome all members wanting to actively participate and share their knowledge and experience. The DDC committee meets the third Wednesday of each month at 11AM, EST/DST.

Webinar Subcommittee

  • Just finished a great webinar on April 26th surrounding Life Care Plans and WCMSAs on April 26th!
  • Our second EBM webinar is scheduled for June.
  • John Cattie will be presenting an MSP Compliance in Liability Claims webinar on July 12th.
  • In August, we’ll be having the 3rd EBM webinar.
  • November's Webinar will be a dedicated webinar towards ethics.
  • In December, we will host a year in review webinar.

Legislative and Case Law Committee

The legislative committee has sent out two short surveys over the last few months to pinpoint the most relevant MSP issues being faced by the membership. If you have not taken this survey, please click this link and respond.  Once the results are in, the legislative committee will develop short-term and long-term goals of the committee in an effort to address these MSP issues to the extent possible. Thank you for providing your feedback!



 

Welcome New Partner Professional Members





 

 


The NAMSAP Communications Committee would like to encourage you to submit an industry-related article for our upcoming newsletter. We are accepting submissions in the following categories: Legal, Legislative, and Medical. If you are interested in contributing to one of these categories, or have an idea for a new category, please contact Rita Wilson, Communications Committee Chair. She can be reached by email at Rita.Wilson@TowerMSA.com.




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