CMS Issues Updated WCMSA Reference Guide

On November 6, 2013, CMS issued an updated WCMSA Reference Guide to provide additional information on the CMS WCMSA approval process.  The updated Reference Guide includes several new sections, which are outlined below.

• 9.4.1.1—Most Frequent Reasons for Development Requests.  This section discusses the five most frequent reasons for development requests.

• 9.4.2—WCRC Team Background and Resources Used.  This section describes the qualifications of the WCRC reviewers and references the resources that the WCRC uses in the review process.  The WCRC (Workers’ Compensation Review Contractor) is the CMS contractor that reviews WCMSA submissions.

• 9.4.3—WCRC Review Considerations.  This section addresses general factors that the WCRC reviewers look at in reviewing WCMSAs.

• 9.4.4—Medical Review.  This section discusses issues related to the basic process that WCRC reviewers follow in reviewing medical treatment pricing for WCMSAs:

• 9.4.5—Medical Review Guidelines.  This section discusses WCRC pricing guidelines related to the following: diagnostics; spinal cord stimulators and intrathecal pumps; surgeries/procedures; lab tests; TENS units; state-specific statutes; CMS medical records guidelines; and treatment recommended outside a provider’s area of expertise.

• 9.4.6—Pharmacy.  This section addresses WCRC review and pricing guidelines for prescription medications, along with the following topics: CMS’ recognized pharmacy compendia; medically accepted indications and off-label use; compounded drug products; benzodiazepines and barbiturates; PRN or as-needed drugs; physician-dispensed drugs; Part B drugs and drug prices; intrathecal pain pumps; dual-designation drugs; drug weaning; drug tapering; and drug contraindications, drug warnings and precautions, and drug Interactions.

Upcoming Webinar: Medicare Advantage Plans

Medicare Advantage Plans and Part D Prescription Plans:

What is the Big Deal?

 Join Us for a FREE Client Webinar on November 5, 2013.

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• Do you have questions about Medicare Advantage Plans? 
• What is an Advantage Plan?
• How does it differ from regular Medicare reimbursement?
• How will it impact the way cases are handled?

Join Melisa Zwilling, Esq., Chair of the Medicare Compliance Group at the law firm of Carr Allison, as she addresses each of these questions and more during a free client webinar:

Tuesday, November 5, 2013 at 11:30 Central Standard Time. 

During the presentation, you will have the opportunity to submit questions and receive the answers you need.  As a national leader in Medicare Compliance issues for over twelve years, Melisa and her team have the experience and knowledge necessary to lead you successfully forward.

Space is limited so be sure to register soon!

Government Shutdown Impacts Medicare Secondary Payer Issues

Due to the government shutdown, the employees in the CMS Regional Offices who are involved with Medicare Secondary Payer Compliance have been furloughed. Therefore, as long as the shutdown continues, we anticipate that MSA determination letters will not be issued. We also do not expect to receive any information from the Social Security Administration regarding claimants' public benefits status during the shutdown. We have confirmed, however, that the Workers' Compensation Review Contractor will continue to operate as normal, since it is an independent contractor. Medicare's Coordination of Benefits Contractor and the Medicare Secondary Payer Recovery Contractor will not be impacted for the same reason. We will monitor the situation closely and do everything possible to move files through the process as quickly as possible.

TPOC Threshold for Section 111 Reporting Changes October 1, 2013

Beginning October 1, 2013 the mandatory reporting threshold for workers’ compensation and liability insurance (including self-insurance) is reduced to require reporting of TPOC amounts over $2,000. Reporting of TPOCs which meet the mandatory threshold is required during the RRE’s submission timeframe in the quarter beginning January 1, 2014.  RREs are also given the option to report any TPOCs greater than $300 up to $2,000 although reporting is not required.  Any TPOC reported with an amount equal to or less than $300 will be rejected.  The October 1, 2013 threshold change will likely have a greater impact on liability cases than it does on workers' compensation cases.

All mandatory TPOC reporting thresholds and the corresponding required reporting dates are shown in the table below.  Additional information can be found in Chapter III: Policy Guidance of the NGHP User Guide in the link below.

http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/New-Downloads/NGHPUserGuideVer36Ch3Policy.pdf
 

Medicare Advantage Plans and Prescription Drug Plans and How They Differ from Traditional Medicare

Under traditional Medicare, Medicare beneficiaries receive coverage through Part A (hospital insurance) and Part B (medical insurance).  Medicare beneficiaries may choose to enroll in a Medicare Advantage Plan under Part C as an alternative to traditional Medicare.  Medicare Advantage Plans are offered by private health insurers as a replacement for coverage under traditional Medicare.  If a beneficiary is enrolled in a Medicare Advantage Plan, the plan pays for the beneficiary's treatment that would otherwise be covered under Parts A and B.  In addition to benefits that are otherwise payable under traditional Medicare, some Advantage plans also provide prescription coverage.  Medicare beneficiaries may also receive prescription drug coverage by enrolling in a Prescription Drug Plan under Part D.  Like Medicare Advantage Plans, Prescription Drug Plans are offered by private health insurers.

It is important to keep in mind when resolving conditional payment claims, that the conditional payment letters issued by the Medicare Secondary Payer Recovery Contractor (MSPRC) only apply to payments made under Parts A and B of traditional Medicare plans.  They do not include information concerning Medicare Advantage or Prescription Drug plan liens.  If a claimant is enrolled in a Medicare Advantage or Prescription Drug plan, the identity of that plan should be determined and the plan should be contacted individually to determine whether it intends to assert a lien.

INTERIM RULE IMPLEMENTING ASPECTS OF THE SMART ACT PUBLISHED

CMS recently issued an "Interim final rule with comment period" regarding the ongoing implementation of the SMART Act. This rule will become effective November 19, 2013, and does not create any substantive changes to the Act but does provide more details regarding access to conditional payment information for individuals other than the Medicare beneficiary, and reiterates the obligation to modify the MSP web portal. Public comments on this rule are welcomed and due before 5 p.m. on November 19, 2013, but a notice-and-comment rulemaking procedure is waived with CMS's finding that it is unnecessary and in the public interest to do so. Note that comments made will be available for public inspection at http://regulations.gov.

The current system allows Medicare beneficiaries to access details regarding conditional payment claims on MyMedicare.gov, but third parties who are not authorized by the Medicare beneficiary cannot access any of this information. Even those third parties who are authorized by beneficiaries can find only limited information via MSP's current website.

To enable third parties to access this information, the interim rule proposes an implementation of a 'multifactor authentication.' This will allow an applicable plan (and the beneficiary's representative) access to claim-specific data without the beneficiary's express consent, via an improved web portal.

CMS' plan is to develop this multifactor authentication within 90 days of November 19th and to implement this process no later than January 1, 2016. In theory, this will allow the beneficiary's representative and applicable plans (that have appropriately registered) to access the improved web portal's details and, ultimately, a copy of the formal demand. The website will implement further revisions to allow Medicare beneficiaries and their agents to dispute unrelated claims, update Medicare's statement, obtain time and date stamped information before mediation, and to notify Medicare's contractor of a settlement's terms. This interim rule does not address an applicable plan's right of appeal and appeal process regarding conditional payments; apparently, the rules implementing this aspect of the SMART Act are still forthcoming.

The official version of this interim rule, and the address for submitting comments, can be found at http://www.gpo.gov/fdsys/pkg/FR-2013-09-20/pdf/2013-22934.pdf. We look forward to additional implementation details of the SMART Act and, particularly, the regulations governing an applicable plan's right of appeal and appeal process. Once available, we will provide an immediate and thorough update.

Haro v. Sebelius Case Update

In Haro v. Sebelius, 2013 U.S. App. LEXIS 18353 (Dist. Az September 4, 2013), the Court of Appeals for the Ninth Circuit vacated injunctions entered by the United States District Court of Arizona and reversed the district court’s summary judgment order in favor of a class of Medicare beneficiaries who challenged the Secretary of Health and Human Services’ (Secretary) practice of demanding “up front” payment for conditional payment claims from beneficiaries appealing or seeking a waiver of the reimbursement obligation. The beneficiaries alleged that the Secretary exceeded her authority under the Medicare Secondary Payer Act (MSPA) by (1) demanding payment before resolution of the appeal and waiver processes and (2) by instructing the beneficiaries’ attorney to withhold the settlement funds until Medicare was reimbursed. Unfortunately, the court was unable to address the first issue because this argument had not been included in the beneficiaries’ appeals or waiver requests and thus, Medicare had not yet had an opportunity to address the matter. Here, we are once again reminded of the importance of ensuring that any and all arguments be addressed in Medicare’s administrative appeals process so that, if the matter reaches the court, the court will have jurisdiction over the issue.

The court was able to address the second issue, whether the Secretary exceeded her authority by demanding that the beneficiaries’ attorney withhold the settlement funds until Medicare was reimbursed. The court looked to the reimbursement provision of the MSPA (42 U.S.C. 1395y(b)(2)(B)(ii)) and determined that because an attorney who receives settlement proceeds, even as an intermediary, has received payment from a primary plan in a literal sense, the attorney is an entity that “shall reimburse” Medicare. Thus, it was reasonable for the Secretary to demand that the attorney withhold the settlement funds until Medicare had been repaid.  While the court did not go so far as to decide whether the Secretary has authority to bring an action to recover secondary payments against an attorney who has disbursed settlement proceeds, that would not be a big step from the court’s holding here. Regardless, attorneys should not ignore Medicare’s demand to hold settlement funds in trust until Medicare has been reimbursed. Even without such instruction from Medicare, doing this is the best way to ensure that the conditional payments are resolved and all parties are protected from issues arising in the future.

Upcoming Webinar: Medicare Compliance Updates

Join us for a FREE client webinar on August 29, 2013.  

Melisa Zwilling will discuss the most recent Medicare compliance updates including how to best resolve Medicare Advantage (Part C) liens. Attendees will receive one CE credit hour for the following states: Georgia, Florida & Texas.

Click here to register.

Eleventh Circuit Court of Appeals Confirms Dismissal of Government's Claims in U.S. v. Stricker as Claims are Barred by the Statute of Limitations

The district court recently dismissed the action brought by the federal government in U.S. v. Stricker as barred by the statute of limitations. The government appealed that decision to the Eleventh Circuit Court of Appeals. On July 26, 2013, that court agreed with the district court and affirmed its dismissal of the government’s complaint.

Under the Federal Claims Collection Act, the government is given two different statutes of limitations depending on the action. For actions arising under contracts, the government has six years to file a complaint. For actions arising under torts, the government has only half that time with three years. In the original case giving rise to this action, a settlement was reached on August 20, 2003, and an initial payment was made on August 26, 2003. The plaintiffs’ attorneys had to certify that 75% of the class action plaintiffs had signed a release before the second, larger payment could be made. The releases were certified and the second payment was made on October 29, 2003. After that, the only remaining payments were to be made annually. The settlement was voidable if less than 97% of the plaintiffs had not signed a release. On December 2, 2003, the plaintiffs’ attorneys certified that the required number of plaintiffs had signed a release. The government filed its complaint to recover Medicare payments on December 1, 2009.

The government argued that the statute of limitations did not begin until December 2, 2003, and that the six year statute applied as this claim arose under a contract relationship with Medicare beneficiaries. The plaintiffs to this action, which now included the original plaintiffs, their attorneys, and the original defendants, argued that the government’s claim arose under a tort and thus the three year statute applied. The court did not find it necessary to decide which statute of limitations applied however. The court found that the claim accrued on October 29, 2003, when the initial settlement payment was made. The court cited the Code of Federal Regulations, which clarified when a claim arose under the Medicare Secondary Payer Act. The regulation in question states, "[a] primary payer’s responsibility for payment may be demonstrated by (1) A judgment; (2) A payment conditioned upon the beneficiary’s compromise, waiver, or release . . . ." 21 C.F.R. § 411.22(b). When the original defendants made the second payment on October 29, 2003, the federal government’s time for filing a claim began as this constituted a payment conditioned upon a release. That the contract was voidable if less than 97% of the plaintiffs signed a release did not deter the court, as the court noted that the settlement would proceed to completion if the defendants chose to simply do nothing. As such, the court found that the government’s complaint was not timely made, whether the allowable time frame was three years or six years.

Court Order Not Based Upon a Hearing on the Merits Does Not Limit Conditional Payment Claim Recovery

In Cecelia Taransky v. Sebelius, et al., 2013 U.S. Dist. LEXIS 107429 (D. N.J. decided June 12, 2013), a plaintiff who had previously settled a slip and fall was ordered to repay Medicare its $10,121.15 demand for conditional payment claims.

As a result of the plaintiff's underlying accident, a fall at a shopping center, Medicare had made $18,401.40 in conditional payments. After the plaintiff settled her case for $90,000.00, she requested and obtained an unopposed order from New Jersey's Superior Court. This order provided that "no portion of this recovery ... [was] attributable to medical expenses" (Id. at *5), and plaintiff apparently believed that this would prevent Medicare from recovering their conditional payments. After set

The plaintiff's attorney appealed the demand, unsuccessfully, through Medicare's administrative process, and ultimately filed an action for declaratory judgment and injunctive relief with the District Court of New Jersey. He argued that Medicare was not due reimbursement on various grounds, all of which failed. Because the plaintiff failed to timely raise a due process argument (under both the Fifth and Fourteenth Amendments), the district court was unable to consider this argument. The remaining arguments were almost identical to the arguments that failed in Mason v. Sebelius (Mason v. Sebelius and its failing arguments were previously discussed in our newsletter of April 5, 2012). What makes this case worth our consideration is two "slight tweaks" (Id. at *23) in the arguments made in Mason v. Sebelius: here, plaintiff (who was represented by same attorney, apparently, as the attorney in Mason) obtained an order providing that the recovery was not attributable to medical expenses. Second, plaintiff argued that Medicare's recovery, if it could recover at all, should be limited to the proportion of the settlement proceeds attributable to medical expenses.

Unfortunately for the plaintiff, the court order obtained by Taransky was not based on the merits of the case and as such it did not limit Medicare's right of recovery. Because this order was based only upon an unopposed stipulation of the plaintiff and not on an independent inquiry into the issues, with opposing arguments promoted in an adversarial setting, it could not be used to limit Medicare's recovery. In fact, there was ample evidence that contradicted the order: the lawsuit claimed medical costs as damages, and plaintiff's correspondence to opposing counsel showed that plaintiff's counsel had used the tentative conditional payment letters from Medicare as leverage for settlement. The settlement documents themselves even provided that the plaintiff would be responsible for outstanding conditional payments.

Like the due process arguments that failed, plaintiff's argument that Medicare was only entitled to the proportion of the settlement actually attributable to plaintiff's medical damages was made too late to be considered. It is unfortunate that this argument was not timely made, as (in my opinion) this argument had the most promise of succeeding.

This case is consistent with prior decisions that support Medicare's claim that a plaintiff cannot demand repayment for medical expenses during settlement negotiations and then, to avoid conditional payments, tell Medicare that the settlement ultimately obtained was only for pain and suffering. The upside of cases such as these is that they may ultimately curb the pursuit of unmeritorious claims for medical care damages.
tlement, however, Medicare treated the claim like any other with a Medicare beneficiary: it reduced its claim by its share of attorney fees and demanded repayment of $10,121.15 in related claims.

Medicare Advantage Appeals Alert

In recent years a growing number of courts have addressed the recovery rights of Medicare Advantage plans. Medicare Advantage plans, otherwise known as Part C plans, are offered by private health insurers as a replacement for Medicare hospital insurance (Part A) and medical insurance (Part B). In exchange for Advantage plans providing health coverage to Medicare beneficiaries, Medicare pays Advantage plans a fixed monthly amount for each beneficiary enrolled. Although most Advantage plans only provide benefits that are otherwise payable under Parts A and B, some Advantage plans also provide prescription coverage. Medicare beneficiaries also have the option of enrolling in separate Medicare prescription drug (Part D) plans, which like Advantage plans are offered by private health insurers that receive a subsidy from Medicare. It is important to keep in mind in resolving conditional payment claims that Medicare only asserts conditional payment claims for payments made under Parts A and B. If a Medicare beneficiary is enrolled in a Medicare Advantage or prescription plan, each plan may have a separate lien that should be addressed in settling a case.

Humana, one of the nation's largest Medicare Advantage and prescription drug plan providers, filed four lawsuits over the last two weeks against Farmers Insurance in an attempt to establish new case law supporting the recovery rights of Medicare Advantage plans. The U.S. District Courts in which the cases were filed include the Eastern District of Tennessee, the Western District of Missouri, the District of Kansas, and the Western District of Texas. In each case Humana is asserting claims for double damages for medical expenses that Humana argues should have been paid under no-fault or med pay coverage. As an alternative to double damages, which is based on the amount of Humana’s discounted payments, Humana is seeking payment for the full amount that would have been paid by Farmers if Farmers had issued payment directly to the providers for the charges asserted. Humana has also asked each court to issue a declaratory judgment finding that Medicare Advantage plans are secondary to no-fault and med pay insurance and that Farmers must reimburse a Medicare Advantage plan in situations when Farmers is the primary payer. Finally, Humana has requested that each court order Farmers to provide broad restitution to Humana for medical expenses paid for any Humana plan enrollee when Farmers was the primary payer and had no-fault or med pay coverage.

As noted above, Humana's complaints are focused on no-fault and med pay policies. Farmers allegedly denied payment for Humana's claims on the basis that Farmers had a first party contract with the insured and Humana therefore did not have a valid subrogation lien. As discussed below, Farmers' position is consistent with prior case law holding that Medicare Advantage plans do not have the same direct recovery rights as Medicare and may only assert subrogation claims based on their contract with the insured. According to Humana, however, Farmers should nevertheless have issued payment, as Humana claimed in reimbursement letters that they have the same direct recovery rights as Medicare despite the prior case law supporting Farmers' position.

Prior to the Third Circuit’s decision in In re: Avandia Marketing, Sales Practices, and Products Liability Litigation, 685 F.3d 353 (3rd Cir. 2012), every court that had addressed the issue held that Medicare Advantage plans do not have a cause of action under federal law to recover from primary plans. Instead, courts held that Medicare Advantage plans could only pursue a subrogation claim based on a contract with each insured, which is consistent with Farmers’ description of Humana’s claims as subrogation liens. In the Avandia case, however, the Third Circuit held that a Medicare Advantage plan may assert a private cause of action against an insurer under the Medicare Secondary Payer Act. Earlier this year, the U.S. Supreme Court denied certiorari in the Avandia case. Thereafter, the Ninth Circuit held in Parra v. PacifiCare, 715 F.3d 1146 (9th Cir. 2013) that a Medicare Advantage plan could not assert a private cause of action against claimants under the Medicare Secondary Payer Act, although the Ninth Circuit did not address the rights of Medicare Advantage plans to recover from insurers.

The lawsuits filed by Humana are a clear attempt to extend the Third Circuit’s ruling to other Circuits. Texas is in the Fifth Circuit, Tennessee is in the Sixth Circuit, Missouri is in the Eighth Circuit, and Kansas is in the Tenth Circuit. Given the holdings of U.S. District Courts outside the Third Circuit, these cases should set important precedent concerning the recovery rights of Medicare Advantage plans. We will continue to follow these cases closely and we will provide you with any updated information.

If you have any questions on Medicare Advantage or prescription drug plan liens, please do not hesitate to contact us. If you are uncertain whether a claimant is enrolled in a Medicare Advantage or prescription drug plan, we can help verify that information. We are currently assisting clients in a number of cases with the lien research and negotiation process and we can handle the process in any case in which a Medicare Advantage or prescription drug plan is involved.

CMS Section 111 NGHP July 25th Teleconference Highlights

On July 25, 2013, CMS held a teleconference call to discuss issues with Section 111 reporting for Non-Group Health Plans. Among the issues discussed were the transition to reporting ICD-10 codes, ORM termination with a physician attestation confirming no further treatment is anticipated, issues with Medicare incorrectly denying payment for unrelated treatment due to an open ORM record, a forthcoming Alert addressing amended complaints, potential reporting exceptions for certain types of insurance in cases in which NOINJ would otherwise be reported, and an Advance Notice of Proposed Rulemaking regarding criteria for the imposition of Section 111 penalties.

Beginning October 1, 2014, CMS will start using ICD-10 codes for diagnostic and billing purposes. Currently, ICD-9 codes are used. CMS will accept ICD-10 codes for all claim input and DDE files submitted on or after October 1, 2014. Any production files submitted with ICD-10 codes prior to October 1, 2014, will be rejected. However, RREs may submit test files with ICD-10 codes beginning October 1, 2013. An alert regarding ICD-10 and ICD-9 codes which are excluded from reporting was recently published by CMS. A copy of the alert can be viewed at http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/New-Downloads/Alert-%E2%80%93-Excluded-ICD-9-CM-and-ICD-10-CM-Diagnosis-Codes.pdf.

ICD-10 codes will be required for file submissions with a CMS date of incident on or after April 1, 2015. For file submissions with a CMS date of incident prior to April 1, 2015, RREs may continue to use ICD-9 codes but are encouraged to use ICD-10 codes for files submitted beginning October 1, 2014.

CMS discussed that an RRE may report termination of ORM if the primary care physician provides an attestation confirming that it is not reasonably expected that further treatment will be needed for the injury at issue. RREs do not provide the physician letter to CMS for Section 111 reporting purposes but should maintain the letter in their file. It is not necessary to obtain such a physician attestation if termination of ORM is reported because the RRE’s legal responsibility for payment for treatment has ended.

CMS generally addressed situations in which Medicare incorrectly denies payment for unrelated treatment due to an open ORM record. In many cases where an RRE has reported ORM for a particular injury, Medicare has been initially denying payment for completely unrelated treatment. CMS indicated that they are working to correct these issues and reiterated that in such situations the beneficiary has a right to file an appeal. Although CMS noted that they do not have a definite solution for cases in which medical providers refuse to provide treatment to beneficiaries because Medicare has been incorrectly denying payment in the past, they indicated that the beneficiary may be able to resolve the issue by referring the medical provider to the recent CMS MedLearn article addressing the issue. CMS also suggested that it may be helpful for an RRE to provide the beneficiary with a letter to present to the medical provider explaining that ORM has only been reported for the injury at issue.

CMS confirmed that an Alert addressing amended complaints should be issued in the near future and possibly in the next two weeks. Although CMS did not specify what the Alert would state, we expect that the Alert will address liability and no-fault cases in which a complaint initially alleges an injury, ingestion, or exposure on or after December 5, 1980, and the complaint is subsequently amended to only allege an injury, ingestion, or exposure prior to December 5, 1980. In general, RREs are not required to report liability or no-fault cases when the case does not involve an actual or alleged injury, ingestion, or exposure prior to December 5, 1980, and no such injury, ingestion, or exposure is specifically released.

CMS indicated that they are considering creating exceptions for reporting cases involving certain types of insurance when NOINJ would otherwise be reported. NOINJ is reported in cases when there is no allegation of a situation involving medical care or a physical or mental injury and the settlement, judgement, award, or other payment releases or has the effect of releasing medicals. The specific types of insurance CMS listed as being considered for a reporting exception are employment practices liability insurance, directors and officers liability insurance, professional liability insurance other than medical malpractice insurance, fiduciary liability insurance, and errors and omissions insurance. CMS also indicated that they are considering creating an exception for cases involving loss of consortium when NOINJ would otherwise be reported.

CMS discussed that an Advance Notice of Proposed Rulemaking is forthcoming to solicit comments on proposed criteria for the imposition of Section 111 reporting penalties, as required by the SMART Act. Although CMS indicated that they could not currently comment on the Advance Notice of Proposed Rulemaking, it is expected to be published in September 2013. We will keep you informed of any developments in CMS’s issuance of the Advance Notice of Proposed Rulemaking and implementation of the SMART Act.

Carr Allison's Jessica Silinsky Authors Article for California Self-Insurers Association

Jessica H. Silinsky is a contributing author to the current issue of the California Self-Insurers Association's newsletter, Self-Insurance Perspectives. Jessica's article, "Challenging Medicare's Claim," addresses the recent passage of the SMART Act and how it impacts payments made to Medicare under the Medicare Secondary Payer Act.

Ms. Silinsky is a shareholder with the Medicare Compliance Group of Carr Allison and is a resident in its Birmingham, Alabama office.

To read the article, please click here.

Pharmacist Prescription Reviews Save Clients Money!

Recently, Carr Allison teamed with Carlisle Medical in a pharmacy review for a client due to the high cost of a claimant's prescription medication. Carlisle Medical's pharmacist reviewed the claimant's medication regimen and recommended two alternatives. After a meeting with the treating physician, he agreed to change the claimant's medications to exactly what the pharmacist recommended! This change resulted in an annual savings to the client of $5,141.16 and a reduction of $133,670.00 in the recommended Medicare Set-aside amount!

This case is just one example of how Carr Allison and Carlisle Medical work together to help control the cost of prescription medications and save clients money.  Contact us to discuss how we can save you money too! 

Click here to learn more.

Wisconsin Court Rules That a Hospital Can Enforce a Lien Against Tort Claims Even After Medicare Billing Period Has Expired

Recently in Laska v. General Casualty Company of Wisconsin, 2013 Wisc. App. LEXIS 234 (Wis. Ct. App. 2013), the Wisconsin Court of Appeals reviewed the decision of a circuit court that allowed the defendant, University of Wisconsin Hospital, to assert a lien against the tort claims of its patient, plaintiff J. Conrad Laska, after expiration of the time period within which the hospital could have billed Medicare for treatment. The plaintiff was eligible for Medicare when he was injured in an automobile accident. The plaintiff was treated by the defendant hospital for those injuries. Instead of billing Medicare for its treatment of Mr. Laska, the hospital filed a statutory lien against “any tort claims” and “any settlement or judgment resulting from those claims.” Id. at *P1. Subsequently, the deadline for billing Medicare passed, and the plaintiff sought to have the hospital’s lien removed. The circuit court held that the hospital was not required to withdraw its lien.

On appeal, the plaintiff argued that the circuit court erred in interpreting federal Medicare laws to allow the hospital to enforce a lien after the expiration of the time period within which the hospital could have billed Medicare for treatment. The plaintiff also argued that Dorr v. Sacred Heart Hospital, 228 Wis. 2d 425 (Wis. Ct. App. 1999), bars enforcement of the lien.

As to the interpretation of Medicare laws, the plaintiff argued that a federal Department of Health and Human Services memorandum, published in 2000, prohibits providers from enforcing liens against third parties once the time has elapsed in which to bill Medicare. The 2000 HHS memo attempted to clarify the Medicare Provider Agreement Statute, 42 U.S.C. § 1395cc, which aims to ensure that no Medicare beneficiary or other person is charged for services if a beneficiary is entitled to have Medicare pay for those services. The Wisconsin Court of Appeals held, however, that a person is not “entitled” to Medicare when Medicare is a secondary payer and when the primary payer can be reasonably expected to pay. Therefore, the court reasoned, the 2000 memo misconstrued federal law when it prohibited providers from maintaining liens against tort claims after the Medicare billing deadline when Medicare is a secondary payer so long as the primary payer can be reasonably expected to pay.

In its reasoning, the court relied upon 1995 and 1996 HHS memoranda, which established that a provider may, subject to certain restrictions, bill either Medicare or an insurance settlement—even by lien—as long as it does not pursue payment from both Medicare and the liability settlement. The court noted that these memos do not require that all liens be satisfied prior to the Medicare billing deadline.

As to the 2000 memoranda, the court noted that it was not bound to follow the interpretations of the federal law as set out in the memo given that there was an “obvious disconnect between the language of the Provider Agreement Statute and the 2000 Memorandum’s interpretation of that statute.” Laska at *P46. The court further reasoned that previous court decisions, including Oregon Association of Hospitals v. Bowen, 708 F. Supp. 1135 (D. Or. 1989), and American Hospital Association v. Sullivan, 1990 U.S. Dist. LEXIS 6306 (D.D.C. May 24, 1990), support the view that a person is not “entitled” to Medicare payments under the Provider Agreement Statutes “as long a liability insurer can be reasonably expected to pay.” Laska at *P38. Finally the court notes that the cost-shifting purpose of the Medicare Secondary Payer Act would be defeated given that providers would never pursue claims against non-Medicare insurers unless they could be certain that all claims would settle prior to the Medicare billing deadline.

In Laska, the Wisconsin court also addressed the plaintiff’s argument that another Wisconsin case, Dorr v. Sacred Heart Hospital, 228 Wis. 2d 425 (Wis. Ct. App. 1999), bars enforcement of the lien against the plaintiff’s tort claims. The court noted that the Dorr case was factually distinct from Laska in that it involved an HMO and did not address the Medicare statutes.

CMS Issues Top Submission Errors and Helpful Hints

CMS recently released an updated list of top submission errors and helpful hints.  No significant changes were noted from what CMS has been requiring for some time.  A copy of the document may be downloaded from the following site:  http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Submission/WCMSA-Submission.html.

CMS Issues Alert Regarding Transition to ICD-10 Codes for Section 111 Reporting

The Centers for Medicare & Medicaid Services (CMS) has published a Technical Alert detailing the transition from ICD-9 codes to ICD-10 codes in diagnosis coding and Section 111 reporting. The entire Alert can be found at http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/S111ICD10Alert.pdf.

As noted in our January 3, 2013, newsletter, ICD-10-CM codes are replacing ICD-9-CM codes in Section 111 reporting beginning October 1, 2014. At that time, CMS will begin using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for diagnosis coding. ICD-10-CM codes tend to be more detailed than ICD-9 codes, and contain 3 to 7 digits (instead of the 3 to 5 digits used with ICD-9-CM).

The Technical Alert published on June 11, 2013, provides further technical details regarding the transition from ICD-9-CM to ICD-10-CM codes, how the claim input files will be revised, and which ICD-10 codes will be considered valid. In general, Responsible Reporting Entities (RREs) can begin testing the changes to Section 111 fields on October 1, 2013, and are encouraged to begin using ICD-10 codes on production files on October 1, 2014. For dates of injury on or after April 1, 2015, valid ICD-10 codes must be used on all "add" or "update" records.

Another revision to the User Guide is forthcoming which details these changes. We will let you know when this newer User Guide is published and becomes available.

Court Affirms That Social Security Number Is A Material Term of Settlement

Recently, in the case In Re Asbestos Products Liability Litigation, 2013 U.S. Dist. LEXIS 76346 (E.D. Pa. May 8, 2013), a husband's estate and the wife negotiated a settlement with the defendants.  Thereafter, the defendants refused to release settlement funds until the spousal plaintiff (who had asserted only a loss of consortium claim) provided her Social Security number (SSN). The defendants claimed that this information was necessary to comply with Section 111 reporting requirements. Plaintiffs responded by filing a motion with the court to enforce the settlement agreement (which did not contemplate the procurement of an SSN). The plaintiffs argued that the SSN was not necessary because the spousal plaintiff's loss of consortium claim did not involve any damages related to medical care. 

The court first noted that Section 111's reporting rules clearly consider a loss of consortium claim potentially reportable. Thus, "it is permissible for a defendant to condition settlement on the production of a plaintiff’s SSN." Id. at *16-17. The court went on to say that, while state law may prevent the recovery of medical expenses from loss of consortium claims, that did not excuse the defendants from their Section 111 reporting requirements.

Because the defendants were obliged in this case to report under Section 111, and a required element to report under Section 111 is the SSN of a plaintiff, the court noted "the provision of this information is a material term of the settlement agreement that was never agreed upon by the parties." Id. at *17-18. Thus, the magistrate’s recommendation was that the settlement agreement was incomplete and unenforceable.

This decision is in line with a growing number of cases supporting a defendant’s ability to obtain a plaintiff’s SSN for purposes of reporting under Section 111.  Although Congress instructed CMS to make the provision of SSNs optional under Section 111, given the unlimited extensions that are available for CMS to actually accomplish that, the issue of SSNs will likely continue to arise in cases for the foreseeable future.

Medicare Expected to Remain Solvent for Two Years Longer than Previously Projected

The Medicare Trustees just announced that the Medicare Hospital Insurance trust fund is expected to remain solvent for two years more than recently projected, meaning until the year 2026. Marilyn Tavenner, Administrator of the Centers for Medicare and Medicaid Services (CMS), stated that, under the Affordable Care Act, CMS is taking steps "to improve the delivery of care for seniors with Medicare," which aim to "reduce spending while improving the quality of care, and are an important down payment on solving Medicare’s long term financial issues."

According to CMS, other factors that contributed to the improved outlook include lower Part A spending in the past year and lower projected costs of the Medicare Advantage program. The Affordable Care Act is expected to reduce spending in the Medicare Advantage program by a higher amount than previously projected. In addition, Medicare spending per beneficiary has been growing more slowly in recent years.

New Jersey Court Determines Adequacy of Liability Medicare Set-aside

In DuHamell v. Renal Care Group East, Inc., et al. and Catherine Ney v. Renal Care Group East, Inc., et al., 2012 N.J. Super. LEXIS 201 (decided December 7, 2012, and released for publication May 16, 2013), plaintiffs DuHamell and Ney mediated their liability claims with the defendants.  During the mediation, the parties agreed to settle all claims pending a liability Medicare Set-aside determination by CMS.  Upon submission of the settlement terms to CMS, however, CMS informed the parties that it did not have the resources to review the proposed liability Medicare Set-asides.  CMS added that its letter declining the opportunity to review the matter was not a safe harbor (or a release) from the parties' obligations to protect Medicare. 

 

Given the response from CMS to their proposal, and because the settlement agreement provided that a CMS determination would be obtained before the settlement could be finalized, the plaintiffs believed they were unable to settle their claims.  With no recourse other than taking the claims to trial, the plaintiffs turned to the court and requested (1) confirmation that the proposed Medicare Set-asides appropriately protected Medicare's interests and (2) an enforcement of the settlement agreement.

 

While most of the settlement terms were kept confidential, the record does reveal that Ney proposed an MSA of $13,689.25 and DuHamell proposed an MSA of $114,246.00.  The court agreed to review the adequacy of the proposed MSAs in the interests of fairness and public policy.  The court opined that, "to require plaintiffs to force their case to trial when they have reached an amicable resolution outside of court runs contrary to New Jersey's strong public interests in encouraging settlements." Id. at *8.  After reviewing the plaintiffs' expert reports regarding the proposed set-aside amounts, the court found that Medicare's interests were appropriately protected and that the figures were both reasonable and reliable.  Thus, the plaintiffs' unopposed motion to enforce the settlement agreement was granted.

 

DuHamell joins the growing number of cases in which liability plaintiffs and defendants are turning to the courts to resolve the issue of whether a designated sum of money is sufficient to protect Medicare's potential future interests.  It should be noted that liability MSAs are not required.  If a Medicare beneficiary settles a claim and money is being paid, even in part, because of the future medical expenses that will be incurred, however, Medicare's future interest in settlement proceeds should be considered in some manner.  In an increasing number of cases, one or both parties are insisting on "approval" of designated Medicare Set-aside amounts from some type of governing authority.  Even though Medicare is not bound by state court judgments, with no established method for CMS review and approval of liability settlements and an inconsistency between Regional Offices as to whether review will be granted, parties are left with little alternative but to turn to the state courts for assistance.

Workers' Compensation Medicare Set-aside Reform Bill Introduced in Congress

United States Representatives Dave Reichert (R-WA) and Mike Thompson (D-CA) introduced a bill in Congress this week that would amend the Medicare Secondary Payer Act and create significant changes to Medicare Set-asides and the CMS approval process in workers' compensation cases. The title of the proposed legislation is the "Medicare Secondary Payer and Workers' Compensation Settlement Agreements Act of 2013."

 

If enacted, the bill would establish a 60-day turnaround time for CMS to review MSA proposals in workers' compensation cases. For cases in which CMS does not approve the MSA proposal, CMS would be required to provide a specific explanation for each increase in order for the determination to be valid.

 

The bill would also create a formal appeals process for parties in a workers' compensation case to challenge CMS determinations. If CMS does not approve the MSA proposal, parties would have 60 days to file a reconsideration request, and CMS would have 30 days to respond or the original MSA proposal would automatically be deemed approved. Parties would have 30 days to request an ALJ hearing after an unfavorable response to a reconsideration request. If the ALJ issues an adverse decision or fails to issue a decision within 90 days, parties would then be able to seek judicial review of the CMS determination.

 

In disputed workers' compensation cases, the bill would allow the MSA amount to be proportionally reduced based on the extent to which the settlement amount reflects a compromise of the total amount of benefits that could have been payable under state law. This would allow disputed cases to be settled more easily and at lower costs, as CMS currently does not recognize such reductions for workers' compensation MSAs.

 

As an alternative to establishing an MSA account, parties would have the option to pay MSA funds directly to Medicare. Under this provision, Medicare would have no further recourse against the parties with respect to future medical treatment. 

 

In workers' compensation cases where the total settlement does not exceed $250,000.00, the bill would create a "safe harbor" for parties to fully satisfy Medicare's future interests by paying 15% of the current settlement amount directly to Medicare. The bill would allow this provision to be modified if it is determined to have a negative financial impact on Medicare.

 

The bill would limit the amount providers may charge for services for which payment would be issued from an MSA account. Providers would be unable to charge more than the applicable fee schedule, and the parties would not be liable for any amount in excess of the fee schedule.

 

The bill would also create criteria for determining when MSP provisions apply in workers' compensation cases. In addition, parties to a workers' compensation settlement that complies with current federal law could not be subject to any liability imposed by CMS as a result of any subsequent changes in federal law. Further, under the terms of the bill, if a settlement is approved by an appropriate authority under state law, the approval would be binding on CMS with respect to all issues to which state workers' compensation law applies, including any allocation of settlement funds and the projected amount of future indemnity and medical benefits that would otherwise be payable under state law.

 

A press release concerning this bill may be found at:  http://reichert.house.gov/press-release/reps-reichert-and-thompson-introduce-bipartisan-medicare-secondary-payer-and-workers

 

Although the Medicare Compliance Group attorneys at Carr Allison have several concerns with the way the bill is worded, it is certainly a good start to address multiple problems that currently exist.  We will continue to monitor the progress of the bill and keep you informed of any updates from Congress.

Texas Court Finds Medicare Secondary Payer Act Does Not Preempt State Laws Concerning Workers’ Compensation Preauthorization Requirements

A Texas court was recently asked whether the Medicare Secondary Payer Act (MSP) "preempts a state law that requires a workers’ compensation claimant to obtain preauthorization from the relevant carrier before incurring certain medical expenses." Caldera v. The Insurance Company of the State of Pennsylvania, 2013 U.S. App. LEXIS 9706 (5th Cir. May 14, 2013). The plaintiff in this action injured his back in a work-related accident in 1995, and was receiving Medicare benefits by 1998. The plaintiff had back surgeries in 2005 and 2006, for which he did not seek preauthorization. Texas law states that a workers’ compensation carrier is not liable for services and treatments that require preauthorization unless such authorization is sought and granted by either the carrier or the commissioner. Tex. Lab. Code Ann. § 413.014(d). The plaintiff and carrier disputed the surgeries before the Texas Division of Workers’ Compensation, which eventually found for the carrier. The plaintiff sought review in state court and was successful; however that court did not require any payment from the carrier.

Included in the state action was a private reimbursement claim under the MSP seeking double damages against the carrier. The court noted that the plaintiff had not suffered any out-of-pocket loss related to this claim, and it did not appear that Medicare had sought recovery of these funds from either the plaintiff or the carrier. As readers are likely aware, the MSP contains a private right of action allowing citizens to assist Medicare in recovering funds erroneously paid by Medicare. A beneficiary can seek double damages if the carrier qualifies as a primary plan. The plaintiff argued that even though he did not seek preauthorization for his surgeries, as required by state law, the MSP preempts the state preauthorization requirement. The court replied that "[t]he MSP and its implementing regulations do not, however, extend so far as to eviscerate all state-law limitations on payment." 2013 U.S. App. LEXIS 9706 at *8. The court further noted that Medicare does not usually pay until a beneficiary has exhausted his remedies under the state workers’ compensation plan. MSP’s regulations allow Medicare to recover from a beneficiary when the beneficiary fails to make a proper claim under state law. See 42 C.F.R. § 411.24(l). Therefore, the regulations also "accept that Medicare may be unable to recover from a carrier because a beneficiary failed to file a proper claim under state law." 2013 U.S. App. LEXIS 9706 at *10.

Previous decisions in Texas found that when an individual’s right to recovery is limited by state law, the government’s right to recovery is equally limited. Because the plaintiff failed to meet the state preauthorization requirement, the plaintiff’s preemption argument failed. In conclusion, the court wrote that MSP was not intended to "override a primary payer’s ability to impose medical necessity requirements in accordance with state law." Id. at *15.

CMS Publishes New User Guide

CMS recently published a new NGHP User Guide for Section 111 reporting.  The new User Guide, version 3.6, incorporates the March 24, 2013, NGHP Alert as well as other changes to version 3.5.  

The User Guide may be accessed at http://www.cms.gov/Medicare/Coordination-of-Benefits/MandatoryInsRep/NGHP_User_Guides.html. 

Ninth Circuit Addresses Reimbursement Rights of Medicare Advantage Plans

by Matt Dorius, Esq.

The Ninth Circuit is now the most recent court to address the reimbursement rights of Medicare Advantage Plans under the Medicare Secondary Payer Act. In Parra v. PacifiCare, No. 11-16069, 2013 U.S. App. LEXIS 7861 (9th Cir. April 19, 2013), the survivors of a deceased Medicare Advantage enrollee settled a wrongful death claim for $500,000.00. PacifiCare, the Medicare Advantage plan, had paid $136,630.90 in medical expenses related to the accident. In settling the case, the insurer issued a check for $136,630.90 payable jointly to the survivors’ attorney and to PacifiCare’s affiliate, to be held in trust pending resolution of the parties’ claims, and the remainder of the settlement funds was paid to the survivors. The survivors then filed an action in federal district court seeking a determination that PacifiCare was not entitled to any reimbursement because the wrongful death settlement did not include any funds for medical expenses under state law. Rather than addressing the issue of whether the settlement included funds for medical expenses under state law, the district court granted the survivors’ motion for summary judgment on the basis that PacifiCare could not assert a private cause of action under federal law.

In its appeal to the Ninth Circuit, PacifiCare argued that it has a right of recovery under 42 U.S.C. § 1395w-22(a)(4), which allows a Medicare Advantage plan to charge an insurer or individual that has received payment from an insurer. The court, however, found that Congress did not intend to create a federal cause of action under this statute. Instead, the court held that this statute only allows for a right of subrogation based on the Medicare Advantage plan’s contract with the enrollee. PacifiCare pointed to 42 C.F.R. § 422.108(f), which provides that Medicare Advantage plans have "the same rights to recover from a primary plan, entity, or individual that the Secretary exercises under the MSP regulations." The court, however, explained that this regulation could not created a private right of action since none was created by Congress.

PacifiCare also argued that it could assert a private cause of action under 42 U.S.C. § 1395y(b)(3)(A), the portion of the Medicare Secondary Payer Act that allows Medicare to assert a private cause of action against a primary plan and recover double damages. PacifiCare relied on the Third Circuit’s decision in In re: Avandia Marketing, Sales Practices, and Products Liability Litigation, 685 F.3d (3rd Cir. 2012), which held that Medicare Advantage plans may assert a private cause of action against a primary plan under 42 U.S.C. § 1395y(b)(3)(A). As we reported, the U.S. Supreme Court recently denied certiorari in the Avandia case.

The Ninth Circuit held that it did not need to address the issue decided in the Avandia case, whether 42 U.S.C. § 1395y(b)(3)(A) provides Medicare Advantage plans with a cause of action against primary plans, because the private cause of action was inapplicable to PacifiCare’s claim against the survivors. As the court noted, the private cause of action applies "in the case of a primary plan which fails to provide for primary payment." 42 U.S.C. § 1395y(b)(3)(A). PacifiCare, the court explained, had not made any claims against the insurer. Further, the court noted, the insurer could not be subject to a private cause of action, as it had already paid the funds jointly to both parties. As such, the court held that the district court had properly dismissed PacifiCare’s claim.

Court Independently Determines MSA Amount in Liability Case

by Jennifer Smith, Esq.
 
In Benoit v. Neustrom, 2013 U.S. Dist. LEXIS 55971 (April 17, 2013), the Plaintiff petitioned the court to review the liability settlement and proposed Medicare Set-aside amount and issue a judgment declaring that Medicare’s interests were adequately protected. The following evidence was presented to the court: (1) a Medicare Set-aside allocation report, which projected the claimant’s future Medicare-covered medical costs to be in the range of $277,758.62 to $333,267.02, (2) a formal demand for reimbursement of conditional payment claims in the amount of $2,777.88, (3) the settlement amount of $100,000.00, (4) that $55,707.98 was the amount subject to be set aside (this represents the remaining settlement funds after payment of attorney’s fees, expenses, and the Medicare conditional payment claim), and (5) testimony from the Plaintiff’s wife, as well as a financial statement from the Social Security office, regarding the Plaintiff’s financial hardship.  The Plaintiff proposed that 10% of the gross settlement proceeds as an equitable amount to set aside since the settlement represented 10% of the possible recovery if he had prevailed on the liability issues at trial.  The court disagreed with the Plaintiff’s methodology, though it still allowed an equitable allocation so that the Plaintiff’s family could fund a special needs trust for the Plaintiff’s future non-Medicare covered items and services.  In calculating the set-aside amount, the court considered the net settlement amount, $55,707.98, and the mid-point range of the MSA allocation report, $305,512.50, and determined that the net settlement was 18.2% of $305,512.50.  The court applied that percentage to the net settlement proceeds and determined that $10,138.00 should be set aside for the claimant’s future medical expenses that would otherwise be covered by Medicare.

FDA will NOT Approve Generics to Original OxyContin

The original version of OxyContin became available in 1995.  Unfortunately, the original version carried with it a large potential for abuse when the product was crushed.  As a result, the original formula was withdrawn from sale.  Thereafter, in April of 2010, the FDA approved a reformulated version of OxyContin which was difficult to crush and abuse like the original formula.  On April 16, 2013, the FDA approved new labeling for the reformulated OxyContin which indicates that it is much more difficult to abuse.  The press release concerning this issue which appears on the FDA website states as follows:  

FDA approves abuse-deterrent labeling for reformulated OxyContin
Agency will not approve generics to original OxyContin

The U.S. Food and Drug Administration today approved updated labeling for Purdue Pharma L.P.’s reformulated OxyContin (oxycodone hydrochloride controlled-release) tablets. The new labeling indicates that the product has physical and chemical properties that are expected to make abuse via injection difficult and to reduce abuse via the intranasal route (snorting).

Additionally, because original OxyContin provides the same therapeutic benefits as reformulated OxyContin, but poses an increased potential for certain types of abuse, the FDA has determined that the benefits of original OxyContin no longer outweigh its risks and that original OxyContin was withdrawn from sale for reasons of safety or effectiveness. Accordingly, the agency will not accept or approve any abbreviated new drug applications (generics) that rely upon the approval of original OxyContin.

The FDA approved the original formulation of OxyContin in Dec. 1995. The product was abused, often following manipulation intended to defeat its extended-release properties. Such manipulation causes the drug to be released more rapidly, which increases the risk of serious adverse events, including overdose and death. In April 2010, the FDA approved a reformulated version of OxyContin, which was designed to be more difficult to manipulate for purposes of misuse or abuse. Purdue stopped shipping original OxyContin to pharmacies in August 2010.

“The development of abuse-deterrent opioid analgesics is a public health priority for the FDA,” said Douglas Throckmorton, M.D., deputy director for regulatory programs in the FDA’s Center for Drug Evaluation and Research. “While both original and reformulated OxyContin are subject to abuse and misuse, the FDA has determined that reformulated OxyContin can be expected to make abuse by injection difficult and expected to reduce abuse by snorting compared to original OxyContin.”

The FDA has determined that the reformulated product has abuse-deterrent properties. The tablet is more difficult to crush, break, or dissolve. It also forms a viscous hydrogel and cannot be easily prepared for injection. The agency has determined that the physical and chemical properties of the reformulated product are expected to make the product difficult to inject and to reduce abuse via snorting. However, abuse of OxyContin by these routes, as well as the oral route, is still possible. The reformulated product also may reduce incidents of therapeutic misuse, such as crushing the product to sprinkle it onto food or to administer it through a gastric tube. When FDA finds that a new formulation has abuse deterrent properties, the agency has the authority to require generics to have abuse-deterrent properties also.

This notice may be found on the FDA website at:  http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm348252.htm

Ask the Pharmacist - An Opportunity to Have Your Medicare Set-aside Prescription Related Questions Answered

You are invited to participate in our Ask the Pharmacist webinar on Thursday May 16, 2013 at 11:00 Central Standard Time. During this webinar, Sarah Siefert, staff pharmacist at Carlisle Medical, will be answering your questions concerning prescription medications for injured employees and other individuals. On or before May 2, 2013, simply email any question that you would like to have answered during the webinar to mzwilling@carrallison.com. You will have an opportunity to ask follow-up questions during the webinar presentation. Topics may include anything from generic medications to dosage or frequency issues to alternative treatment options. Don't miss this chance to have your questions answered and listen to pharmacist recommendations that could dramatically reduce expenditures on prescription medications!

Space is limited!
Reserve your Webinar Seat Now at:
https://www4.gotomeeting.com/register/785803095