OncologyPMSI Settlement SolutionsSM Appeals To CMS On Drug Review Methods In Medicare Set-Asides
PMSI Settlement Solutions, a leading solutions provider for liability and workers" compensation claims, announced its initiative to address payor concerns regarding the Centers for Medicare and Medicaid Services (CMS) new prescription drug requirement associated with Medicare Set-Asides (MSA"s). As part of this initiative, PMSI Settlement Solutions will work with government affairs experts, industry consultants and other interested payors.
In a memorandum dated April 3, 2009, CMS stated that all future workers" compensation MSA prescription drug pricing methodologies are to be allocated at the Average Wholesale Price (AWP) for that particular drug only. No other pricing, discounting or calculation methods will be recognized or accepted, except the inclusion of generic pricing only if a current generic is available. On June 2, CMS provided guidance that tapering of medications will be considered if the treating physician believes it is possible, that expiration of drug patents for name brand drugs may be considered for discounting and drug utilization review will be considered.
"These new revised criteria incorporate some of the review standards that PMSI has espoused. However, other CMS review criteria will grossly inflate the allocation of future drug costs, which in turn will adversely impact the payors" ability to settle claims," commented Dr. Kent Takemoto, President, PMSI Settlement Solutions. "Furthermore, these inflated future drug cost allocations are not a true representation of "taking Medicare"s interests into consideration," which is the clear legislative intent of the Medicare Secondary Payer Act."
Utilizing scientific and evidence-based rationale, PMSI Settlement Solutions and industry experts will address the issues of concern and recommend an alternative drug review methodology that will provide for fair and equitable allocations. As part of this process, this effort will encourage CMS to take into consideration the many factors that impact price including: AWP pricing versus other benchmarks, use of formularies, contraindications of medications, card programs, and duplication of therapy as well as duration of therapy and future availability of generic products.
PMSI Settlement Solutions" mission is to educate CMS on these issues and to help enable payors to continue to settle claims based upon accurate pharmacy expenditure projections. PMSI is uniquely qualified to lead this effort given its 33 years of experience as a leader in providing services to the Workers" Compensation market as well as the company"s cross-industry expertise in MSA allocations and Pharmacy Benefit Management.
"We are appealing directly to CMS to reevaluate its current drug pricing methodologies and make improvements to reflect current review standards of practice," Takemoto concluded. "Without addressing this, CMS will restrict payors" ability to obtain accurate future drug allocations which will be detrimental to employers, insurers, third party administrators and injured parties alike."
PMSI has published a Perspective, "Reaching Out for a Common Resolution," documenting the affect of the new CMS drug review policy on workers" compensation and liability claims. For more information on the issue and to download a copy of the PMSI Perspective, visit the PMSI Settlement Solutions website at http://www.pmsisettlement.com.
PMSI