Clinically driven solutions ensure appropriate allocations

Changes to the review of drug cost allocations by the Centers for Medicare and Medicaid Services (CMS) has raised settlement costs higher than ever before. As one of the largest providers of Pharmacy Benefit Management services with integrated clinical expertise, PMSI is uniquely positioned to provide payers with solutions that address the appropriateness, frequency and duration of treatment to support an accurate, defensible and cost-effective MSA allocation.

Clinical Cost Containment Review

PMSI's Clinical Cost Containment Review (CCCR) is a three phase program that systematically identifies inappropriate or unnecessary high-cost medical and/or medication treatment, intervenes through collaboration with prescribers to make clinically validated modifications and provides regular follow-up to ensure implementation of the therapeutic modifications and support positive health outcomes.

Medication and Medical Analysis
A comprehensive review of pharmacy and medical treatment identifies potential cost savings in multiple areas of a claim. Clinical pharmacists review all high-cost pharmacy and medical treatments for therapeutic appropriateness of treatment, duration and future medical needs. Clinical nurses, trained in CMS guidelines, review treatment records evaluating all aspects of medical treatment including DME, surgeries, home healthcare, diagnostics and supplies. Utilization control opportunities for medical and drug therapies are identified using evidence-based guidelines and an action plan to address unnecessarily high-cost items is provided.

Peer-to-Peer Outreach
Outreach is performed by specialty-matched peer physician(s) to collaboratively engage the treating physician in a discussion regarding all aspects of the case to determine alternative treatment strategies that are consistent with standards of care and facilitate implementation of recommended changes. The peer physician will attempt to obtain verbal and written clarification of the agreed upon current and/or future treatment recommendations.

Nurse Progress Monitoring
Completed by an RN, this follow-up service includes documented and detailed telephonic communication over a six-month period between the RN and the treating provider to ensure implementation of the therapeutic changes agreed to during Peer-to-Peer Outreach. Regular reports are provided to the adjuster/case manager including a Case Closure Report.

Medicare Set-Aside (MSA) Clinical Outreach

Achieving the lowest defensible allocation requires a clear and specific MSA allocation for submission to CMS. Allocations with vague or outdated treatment plans will prompt CMS to possibly include all potential treatment options in their analysis—resulting in counter-high allocations. Through the MSA Clinical Outreach, PMSI applies pharmacy, medical, claims and legal expertise to identify potential issues that lead to over-allocation. Any items included in the treatment plan that lack proper clarity are identified, such as outdated recommendations or drug therapies where prescribed reason for usage is unclear. An action plan is created to address specific items requiring clarification with the treating physician through Peer-to-Peer Outreach. Following receipt of written clarification on physician letterhead, the MSA allocation is adjusted and submitted to CMS, if requested by the client.

Medication Review

A Medication Review provides an individualized evaluation of an injured individual's pharmacy and medical records by a PMSI clinical pharmacist to identify any medication-related concerns and develop an action plan for problem resolution. The thorough review results in a detailed report that contains specific clinical recommendations regarding the individual’s therapy and the supporting drug information. The report is provided to the claims professional and physician(s) involved in the claim for resolution of identified concerns. When recommendations are followed, a Medication Review helps to eliminate unnecessary or inappropriate therapies, reducing ongoing health care expenses, and the overall claims cost. Intended for high-risk, actively managed cases that either may not be settled or will settle in the next year, the Medication Review helps ensure that the injured individual is on the right medication regimen for optimal long-term outcomes.

Medication Review with Peer-to-Peer Outreach

Upon request after a PMSI Medication Review is preformed, a PMSI physician will reach out to the prescriber(s) and invite them into a collegial discussion to better understand the clinical situation of the claim. The PMSI physician will help educate the prescriber(s) regarding appropriate therapeutic options and facilitate the implementation of the recommended changes to the therapeutic plan.

For information on PMSI Settlement Solutions innovative clinical solutions, email us at contactus@pmsisettlement.com.