House Passes Measure to Delay ICD-10 Transition

STOP THE PRESSES… Possible Delay in ICD-10 Transition

By voice vote on Thursday, March 27, the House approved another temporary (one-year) fix to prevent steep cuts in Medicare’s physician reimbursement scheduled to take effect March 31. It now moves to the Senate which is expected to take action within the next few days. The draft legislation does not address the problems with the Workers’ Compensation Medicare Set-Aside approval process. However, there is language that speaks to a possible delay in the ICD-9 to ICD-10 transition, which could impact the MMSEA Section 111 mandate for reporting ICD-10s.  Other key inclusions include a two year delay in the provision overturning two U.S. Supreme Court decisions that prevented state Medicaid agencies from recovering 100 percent of their medical payments from the proceeds of liability settlements involving Medicaid beneficiaries and at least a one-year delay Medicaid mandated that providers move from ICD-9 coding to much more complex ICD-10 coding which will have a significant impact on insurers data reporting and bill payment functions.

CMS Issued Alert

It was only on this past Tuesday, March 25, 2014, that the Centers for Medicare and Medicaid Services (CMS) published an Alert regarding ICD-10 Diagnosis Codes, which further tightens the list of acceptable codes for Mandatory Insurer Reporting (MIR) purposes.

ICD-10 codes beginning with the letter “Z” are related to factors influencing health status and contact with health services, and are considered invalid for MIR.  This includes all 19 Diagnosis Code fields as well as the Alleged Cause of Injury, Incident or Illness field.

MIR ICD-9 Codes for Free

The Alert also clarifies the use of ICD-10 codes beginning with the letters V, W, X and Y.  These codes are related to external causes of morbidity and mortality, and may only be populated in the Alleged Cause of Injury, Incident or Illness field, as long as they are not on the list of excluded codes in the NGHP User Guide.  Additionally, these V, W, X and Y codes are invalid for use in the 19 ICD-10 Diagnosis Code fields.

Gould and Lamb has applied the appropriate quality audits, alerts, and metrics to ensure our customers are compliant with the transition.  Should you have any questions regarding this or any other topic related to MIR, please contact your MMSEA Compliance Manager or our Reporting Services Department at mirservice.support@gouldandlamb.com or 866-672-3453 ext. 1122.

Additional details on the bill can be found here.

Gould & Lamb Offers Educational Seminar Series

President and COO of Gould & LambWe at Gould & Lamb, LLC are excited to offer a new educational series focused on assisting industry professionals to achieve Medicare and Medicaid compliance. The conference, titled “Jackpot!” and themed to match the casino/convention venues where it will be held, is a two-day event that will be presented at four regional locations – New Orleans, Las Vegas, Atlantic City and St. Louis.

MSP Compliance requires industry professionals to remain educated and updated on current regulations and protocols to avoid any compliance issues and/or fines. Utilizing the wealth of resources available to Gould & Lamb and our highly-experienced team of executives and industry leaders, as well as respected experts from outside the company, presentations at the conference will provide attendees with the most up to date and in-depth information regarding all aspects of Medicare & Medicaid compliance.

There is a web of confusion in the insurance industry relative to MSP Compliance and parties to a settlement are gambling with Medicare benefits every day. We are offering this educational opportunity to address the complexities of considering Medicare’s interests. Our comprehensive program, presented by the most experienced subject matter experts, is sure to provide information for the protection of all parties, while protecting the future of the Medicare Trust Fund for all of us.

In addition to information and networking opportunities, the event will offer 12 CLE/CEU Credits. With topics ranging from Mandatory Insurer Reporting and Conditional Payments, to Medicare Set-Aside and Post Settlement Administration, we have made this conference a “must attend” for industry professionals, claims adjusters, attorneys, risk managers, settlement brokers, self-insured entities and third-party administrators.

For more information on this groundbreaking series, visit the Event Homepage.

About the Author: Deborah Pfeifle is the Chief Executive Officer at Gould & Lamb.  She has industry recognition for clinical excellence in claims management outcomes and for the development and application of clinical best practices for multi-lines of business. She has hands-on Medicare Set-Aside experience working closely with CMS, the Workers’ Compensation Review Center (WCRC) and the CMS Regional Offices. Deborah closely monitors the reconsideration process at Gould & Lamb for all MSAs in which CMS proposes a higher amount.

New Fixed Percentage Option for Conditional Payment Resolution

Christie Luke Vice President Operations

As expected, on November 7th, the Centers for Medicare & Medicaid Services (CMS) implemented a new fixed percentage option for Conditional Payment Resolution (CPR).  The new fixed percentage option makes the process simpler and faster.  Any beneficiary who meets the criteria below can resolve Medicare’s Conditional Payment recovery claim by paying a flat 25% of his/her total liability insurance settlement.

Required Criteria

In order to qualify, all of the following criteria must be met:

  1. The liability insurance settlement must be for a physical trauma based injury, and
  2. The total liability settlement, judgment, award, or other payment is $5,000 or less, and
  3. The beneficiary elects the option within the required time frame
  4. Medicare has not issued a demand letter or other request for reimbursement related to the incident, and
  5. The beneficiary has not received and does not expect to receive any other settlements, judgments, awards, or other payments related to the incident.

When to Exercise the Option

There are some guidelines as to when to exercise the option:

  1. The request must be submitted before or at the time the settlement documentation is submitted.
  2. If a Conditional Payment Notice (CPN) has been issued, the request must be on or before the CPN response is due (30 days from the date of the CPN).

In order to elect this option, documentation must be completed by the beneficiary or his representative, and mailed to the MSPRC.  Requests are processed in the order received.  So, it is imperative that when selecting this alternative the request is submitted timely.

If the request is denied, a formal letter will be provided with an explanation, and a regular Demand will be sent under separate cover.  If approved, the beneficiary will receive a bill for the amount specified (i.e. 25% of the settlement).

Wait & See

As indicated in our previous Industry News Bulletin of October 26th, the new procedure is a seemingly good way to speed up the process on ‘smaller’ Liability settlements.  However just how many claims will meet this criteria is yet to be determined.


About the Author: Christie Britt is the Vice President of Operations overseeing the extensive operations of Gould & Lamb.   She has vast knowledge of Medicare Set Asides and Post-Settlement Administration from an insurance claims perspective. Christie is MSCC certified and has her Green Belt Certification in Six Sigma.  She is also a member of the National Association of Medicare Set Aside Professionals (NAMSAP) and the Workers’ Compensation Claims Professionals (WCCP).

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.

Complexity of Off Label Drugs Prompts CMS to Exclude Off Label Medications

William F BellOff Label Drugs – Part One

As we know, off-label prescribing is both commonplace and legal in the United States; it is off-label marketing that is suspect. Off Label drugs can be defined as the use of a medication outside of its specific Federal Drug Administration (FDA) indication. An examination of 160 of the most commonly prescribed medications showed that off-label use accounted for 21% of these medications, while 74% of these prescriptions written for conditions not medically supported by the literature (Stafford, 2008). A well-known medication in the Workers’ Compensation (WC) world, Gabapentin (Neurontin) has close to 10 off-label drug indications in addition to its FDA indications of both seizure management and post-herpetic neuralgia.

As part of the changes outlined in its guidance for submitters memo (June 1, 2009), the Centers for Medicare Medicaid Services (CMS) memo determined that prescription medications used for any condition or indication, whether FDA approved or not, were to be included when calculating the final costs associated with Part-D of a Workers’ Compensation Medicare Set Aside  WCMSA. This meant that medications, such as Actiq and Lidoderm, must be allocated for in a WCMSA, even though they are used for conditions not routinely seen in Workers’ Compensation cases. Through their professional and medical judgment, physicians are free to write for prescriptions regardless of the condition it is intended to treat.

Possibly due to pressure or in keeping with the Medicare Part-D statute, CMS reversed its previous position on the inclusion of off-label medications in a WCMSA. Essentially, CMS will now exclude those prescription medications, which are not FDA, approved for a particular indication and are not supported by one or more citations in the compendia. The compendia includes the American Hospital Formulary Service Drug Information (AHFSDI), United States Pharmacopeia- Drug Information (USPDI), and the DRUGDEX Information System. Now, Actiq and Lidoderm can be excluded from the final Part-D costs in a WCMSA as their off label uses are not supported by the compendia.

How Complex Is the Off Label Drug Issue?

Off label drug complexitiesThe above examples show just how complex the off-label drug issue really is.

First – we need to understand the specific FDA indications of medications utilized.
Second – we need a thorough understanding of what exactly the compendia is and how the literature can be interpreted and validated for accuracy, free from bias.
Third – we need to put both together and come up with a sound clinical judgment to in deciding which medications should be included and excluded from a WCMSA, thereby providing a safe and effective medication regimen for long-term use.

As a licensed pharmacist for close to twenty years, I fully understand both the pros and cons with off-label use of medications.

The Pros

A wider access to medications for those with rare conditions resulting in lower medical expenditures and hospitalization costs.

The Cons

Unsupported, undocumented research and safety profiles with use of medications for conditions that they had not been originally tested for.

However, since a majority of workers’ compensation claimants use medications for chronic and not rare conditions, (such as pain management), off-label exclusion of medications is one way to contain both the costs in an WCMSA as well as allocated for safe and effective medications while not adding to unnecessary costs and secondary conditions.

Be sure to watch for my post on Off Label Drugs – Part 2 which will focus on the compendia and the complexity of these findings as well.

Click Here to Download the MSP Compliance Protocols User Guide from Gould and Lamb

Download our Medicare Secondary Payer  Compliance User Guide