On June 2, 2009, CMS published new guidelines with regard to prescription drug documentation for Medicare Set Aside allocators.  A copy of the memo can be found on the CMS website.

The memo includes these main points:

• Pricing of prescription drugs is to be based on the current REDBOOK Drug Reference
• Allocators are to use the lowest priced generic drug listed in the reference
• Tapering WILL BE CONSIDERED by CMS as recommended by the treating physician
• Off-label use does not preclude the prescriptions from the allocation and are allowed so long as the drug is FDA approved
• Generic pricing is only used for generics that already exist
• Failure to submit prescriptions results in Medicare’s use of BRAND NAME PRICING
• Those submitting allocations are encouraged to present any evidence helpful towards a determination

This publication stresses that CMS and the WCRC will review the evidence provided on a case-by-case basis with regard to these prescription  drug allocation decisions.  These new guidelines are just one more reason to hire an allocator with the proper medical and legal skills to create persuasive allocations with the best evidence available.

Our staff allocator, Victoria Powell, is a nurse who is familiar with the medical records and the related terminology as well as expectations for treatment.  As a case manager, Victoria understands that the medical records do not always adequately reflect the long term expectations for a patient’s treatment.  She is assertive and with her experience in case management, she can collaborate with the physicians when crafting the allocation to insure it is done correctly and eliminate any unnecessary services. Furthermore, Ms. Powell is certified as a Medicare Set-Aside consultant.  Don’t risk your allocation to a “report writer.”

How do you feel about these new guidelines?  Fair? What problems do you foresee?

Tagged as: case management, Medicare Set Aside, MSA, WCMSA