Category: Daily News

Tampa, Florida-based CompPharma is a consortium of pharmacy benefit managers. It’s 9th annual survey report, titled “Prescription Drug Management in Workers’ Compensation” states that claims “payers have gotten the message: narcotics are highly problematic for workers’ comp claimants, employers and insurers.” The new survey confirms that addiction to opioid pain medications and the dispensing of drugs by doctors remain top concerns for workers’ compensation companies. The report relies on survey responses from insurers, third-party administrators, and employers with prescription expenses totaling nearly $475 million.

Concern over the long-term implications of prescribing narcotic pain medications to injured workers has grown during the past two years with respondents to this year’s survey conducted by CompPharma L.L.C. saying the issue remains “very significant.”

Despite relatively flat drug costs, respondents continue to be significantly concerned about the issue. In response to the question “How big a problem are drug costs?” on a 1 through 5 scale with 3 being “drug costs are equally as important as other medical cost issues,” drug costs were rated a 4.1, or “more important than other medical cost issues.” This was three-tenths of a point higher than last year’s results (3.8). Moreover, respondents are concerned (4.2) that drug costs will be more of a problem in the next 12-24 months than they are today.

And consistent with results from last year, respondents judged opioids to be a very significant problem, giving it an average of 4.8, identical to responses in the 2011 survey. This is the highest score for any survey question in the history of the survey, and a clear indicator of the level of the industry’s anxiety over a problem it has yet to fully understand, much less address.

The concern over physician dispensing has grown over the last few years, driven by payers’ own experience and the research from NCCI and WCRI quantifying the dramatic increase in the percentage of drug dollars going to pay for physician-dispensed medications.

In 2010, many responses noted newly implemented programs or steps designed to address opioid use. In 2011, implementing and upgrading those programs was the most common change to respondents’ pharmacy management programs.

Half of all respondents utilized a “urine drug-testing program to monitor claimant compliance.” Among those who did not answer in the affirmative were payers that operated in states where they could not require UDT, although they did encourage or recommend testing whenever possible. Others did not have “formal” programs but did reimburse for UDT and were in the process of setting up a program, or were discussing a program with their PBM. There is a clear indication that this tool is growing in popularity.

Pharmacy management in workers’ comp has evolved dramatically over the nine years that surveys have been taken. From a focus on the price of the pill and the size of the retail pharmacy network in 2003 to today’s concern about opioids, physician dispensing and clinical management, there has been a remarkable increase in sophistication and understanding. With that said, it is evident that despite all the attention paid to and resources focused on this issue, payers’ level of concern about pharmacy management continues to remain quite high.

Scientists have long searched for a method to objectively measure pain and a new study from Brigham and Women’s Hospital advances that effort. The study appears in the January 2013 print edition of the journal Pain.

Specifically, researchers studied 16 adults with chronic back pain and 16 adults without pain and used a brain imaging technique called arterial spin labeling to examine patterns of brain connectivity (that is, to examine how different brain regions interact, or “talk to each other”). They found that when a patient moved in a way that increased their back pain, a network of brain regions called Default Mode Network exhibited changes in its connections. Regions within the network (such as the medial prefrontal cortex) became less connected with the rest of the network, whereas regions outside network (such as the insula) became connected with this network. Some of these observations have been noted in previous studies of fibromyalgia patients, which suggests these changes in brain connectivity might reflect a general feature of chronic pain, possibly common to different patient populations.

“This is the first study using arterial spin labeling to show common networking properties of the brain are affected by chronic pain,” said study author Ajay Wasan, MD, MSc, Director of the Section of Clinical Pain Research at BWH. “This novel research supports the use of arterial spin labeling as a tool to evaluate how the brain encodes and is affected by clinical pain, and the use of resting default mode network connectivity as a potential neuroimaging biomarker for chronic pain perception.”

“While we need to be cautious in the interpretation of our results, this has the potential to be an exciting discovery for anyone who suffers from chronic pain,” said Marco Loggia, PhD, the lead author of the study and a researcher in the Pain Management Center at BWH and the Department of Radiology at Massachusetts General Hospital. “We showed that specific brain patterns appear to track the severity of pain reported by patients, and can predict who is more likely to experience a worsening of chronic back pain while performing maneuvers designed to induce pain. If further research shows this metric is reliable, this is a step toward developing an objective scale for measuring pain in humans.”

The U.S. government launched a sweeping study of rising sports-related concussions amid concerns that the injuries may have contributed to the suicides of professional football players.

Returs Health reports that the Institute of Medicine, part of the National Academies of Science, will probe sports-related concussions in young people from elementary school through early adulthood. The study will include military personnel and their dependants, and review concussions and risk factors.

The study, one of the most extensive ever done, will be scrutinized intently by Americans worried about brain injuries in sports, said Robert Graham, head of the panel carrying out the study. “You start talking about, ‘Is it safe for Sally to be playing soccer?,’ you get lots of public interest,” Graham, a public health expert at George Washington University in Washington, told Reuters after the committee’s first meeting. He said the panel likely would submit its report to the Institute of Medicine in the middle of the summer, with publication expected in late 2013.

A 2010 study by the U.S. Centers for Disease Control and Prevention (CDC) found that U.S. emergency rooms yearly treat 173,000 temporary brain injuries, including concussions, related to sports or recreation among people less than 19 years of age. The number of emergency room visits for such injuries rose 60 percent in the previous decade among children and adolescents, the CDC study showed.

A separate 2007 study showed that the incidence of brain injury was highest in football and girls’ soccer. About 2,000 former National Football League players sued the league last year, alleging it concealed the risk of brain injury from players while marketing the ferocity of the game. Many of these same players have filed workers’ compensation claims in California claiming that head injuries decades ago have caused dementia in later years.

Concerns about a possible link between concussions and mental illnesses, such as depression, grew in the wake of the suicides of former NFL players Junior Seau, Ray Easterling and Dave Duerson in the last two years.

Participants at the committee’s meeting said there was a shortage of data on sports-related concussions among young people. The number of relevant brains available for study is in the single digits, and many studies lack breakdowns by age.

Sponsors of the study include the Department of Defense, the CDC and the National Institutes of Health. The panel will also examine studies being done by the CDC and the American Academy of Neurology.

The Department of Industrial Relations and its Division of Workers Compensation (DIR/DWC) announced new regulations implementing provisions of Senate Bill 863, California’s landmark workers’ compensation reform signed last year by Governor Edmund G. Brown Jr. to save businesses millions of dollars in unnecessary costs while boosting worker protections. “We are on track to implement the wide-ranging reform which was the result of extensive input by workers and employers,” said DIR Director Christine Baker. “These reforms are engineered to reduce unnecessary costs while redirecting some of the savings to increase benefits for disabled workers.”

Key components of Senate Bill 863, which became law on January 1, 2013, include a 30 percent increase in permanent disability indemnity rates for workers phased in over two years. Other aspects of the bill, including those designed to cut costs for businesses, will now be implemented through regulatory action. Today’s new regulations launch that full rulemaking process with public hearings scheduled to take place by March.

The new regulations, approved on an interim basis by the Office of Administrative Law, improve workers’ compensation by creating an independent medical panel to review injuries, streamlining billing disputes and curbing unnecessary liens. Details of these new regulations include:

Utilization Review, Independent Medical Review – For injuries on or after Jan. 1, 2013, and effective July 1, 2013 for all dates of injury, medical treatment disputes will be resolved by physicians through an efficient process known as independent medical review (IMR), rather than through the often cumbersome and costly adjudication system. If utilization review denies, delays or modifies a treating physician’s request for a specific course of medical treatment for the reason that the treatment is not medically necessary, the injured employee will have the right to request a review of that decision by IMR conducted by a physician. The physician review will be expeditious and based upon evidence-based standards to ensure that injured employees receive timely and appropriate medical treatment.

Qualified Medical Evaluator Regulations and PDRS – The new regulations amend existing rules to clarify that independent medical review is the sole process for resolving disputes regarding ongoing medical treatment issues; limits the number of offices from which a Qualified Medical Evaluator (QME) may conduct evaluations; streamlines the application process for chiropractors; allows for factual corrections of a comprehensive medical-legal report from a QME panel; and amends a number of forms.

Independent Bill Review– Medical service billing disputes for dates of service on or after Jan. 1, 2013, will be resolved through a non-judicial process of independent bill review (IBR). The IBR applies to any medical service bill where the fee is determined by a fee schedule adopted by the DWC. If the medical provider disagrees with the amount paid by a claims administrator on a properly documented bill following a second review, he or she can request an IBR. This regulation will eliminate unnecessary, costly litigation.

Electronic document filing and lien filing fee – Any lien for reasonable medical expenses incurred by or on behalf of the injured employee (except disputes subject to independent medical review or independent bill review) and filed on or after Jan. 1, 2013, is subject to a lien filing fee of $150. For those liens filed before Jan. 1, 2013, there will be a $100 activation fee which must be paid prior to Jan. 1, 2014, or the lien will be subject to dismissal by operation of law.

Self-Insurance and Annual Actuarial Reports – These new regulations will implement SB 863’s requirement for all private self-insured employers and groups to obtain an actuarial report to more accurately establish the organization’s California workers’ compensation liability exposure. The regulations will further define new methods in how the OSIP establishes security deposit collateral requirements based on this additional information.

Interpreter Services – SB 863 amended Labor Code section 4600(g) to state that an injured worker is entitled to the services of a “qualified interpreter” at medical appointments if the injured worker is not proficient in English. These regulations define the “qualified interpreter for purposes of medical treatment appointments” as “an interpreter who has a documented and demonstrated proficiency in both English and the other language; a fundamental knowledge in both languages of health care terminology and concepts relevant to health care delivery systems; and education and training in interpreting ethics, conduct and confidentiality” so that employers can furnish, and non-English-speaking injured employees can receive, interpreter services at medical treatment in accordance with the statute.

Supplemental Job Displacement Benefits – Makes modifications reflecting regulatory changes regarding offers of work, notifications and vouchers for retraining workers injured on the job.

Hospital outpatient departments and ambulatory surgical centers fee schedule – The statute also amended the official medical fee schedule for hospital outpatient departments and ambulatory surgical centers, reducing the facility fee for ambulatory surgical center services to 80 percent of what Medicare bills for the same services in a hospital outpatient. This change will save an estimated $62 million plus additional savings in system costs. The regulation is effective Jan. 1, 2013.

Extensive information on workers’ rights and employers’ responsibilities as well as information for small business owners can be found on DIR’s website. DIR’s rulemaking web page includes a quick overview of regulations and is updated regularly.

Florida-based American Sleep Medicine LLC has agreed to pay $15,301,341 to resolve allegations that it billed Medicare, TRICARE – the health care program for Uniformed Service members, retirees and their families worldwide – and the Railroad Retirement Medicare Program for sleep diagnostic services that were not eligible for payment, the Justice Department announced today.

American Sleep, headquartered in Jacksonville, Fla., owns and operates 19 diagnostic sleep testing centers throughout the United States, including in Alabama, California, Delaware, Florida, Illinois, Indiana, Kansas, Kentucky, Maryland, Missouri, New Jersey, Tennessee, Texas and Virginia. The company’s primary business is to provide testing for patients suffering from sleep disorders such as obstructive sleep apnea. The test results are used by doctors to determine the most appropriate course of treatment for patients. The most common tool used to diagnose sleep disorders, particularly sleep apnea, is a procedure called polysomnographic diagnostic sleep testing. Under federal program requirements for the reimbursement of claims submitted for sleep disorder testing, initial sleep studies must be conducted by technicians who are licensed or certified by a state or national credentialing body as sleep test technicians.

The United States contend that Medicare and TRICARE claims submitted by American Sleep during this period were false because the diagnostic testing services were performed by technicians who lacked the required credentials or certifications, when it knew this violated the law. American Sleep submitted false claims to Medicare and TRICARE between Jan. 1, 2004, and Dec. 31, 2011, according to the United States’ allegations.

The allegations covered by today’s settlement were raised in a lawsuit filed against American Sleep under the qui tam, or whistleblower, provisions of the False Claims Act. United States ex rel. Daniel Purnell v. American Sleep Medicine LLC, no. 3:07-cv-12-S (W.D. Ky.). The act allows private citizens with knowledge of fraud to bring civil actions on behalf of the United States and share in any recovery. Relator Daniel Purnell will receive $2,601,228 as part of today’s settlement.

In addition to the $15.3 million payment, American Sleep entered into a five-year Corporate Integrity Agreement with the Office of Inspector General of the Department of Health and Human Services. The agreement requires enhanced accountability and wide-ranging monitoring activities conducted by both internal and independent external reviewers.

Principal Deputy Assistant Attorney General Delery thanked the Office of the Inspector General for the Department of Health and Human Services, the Medicare Railroad Retirement Program, the Defense Criminal Investigative Service, the FBI, the U.S. Attorney’s Office for the Western District of Kentucky and the Commercial Litigation Branch for the collaboration that resulted in today’s settlement. The claims settled by this agreement are allegations only, and there has been no determination of liability.