Medicare Compliance and the Opioid Epidemic - How Policy Changes May Impact Future Treatment


The opioid epidemic has become the subject of much conversation over the last few years following increases in substance abuse and deaths resulting from the improper use of opioid medications. The Department of Health and Human Services and the Centers for Medicare and Medicaid Services are actively working to combat the epidemic through a number of strategies, some of which could greatly impact the standard of care and appropriate treatment recommendations for certain conditions moving forward. Although the goal of such efforts is to reduce abuse, the changes and policy decisions implemented have a direct impact on future treatment costs in cases involving Medicare Set-asides. We are closely monitoring HHS’ efforts to combat the opioid epidemic and the policies that could impact the Medicare Compliance issues. We will keep you informed of the changes that may impact you as they come along.

Obviously one of the first goals in combating the epidemic is preventing abuse in the first place. HHS is doing this by working to reduce the volume of opioids prescribed. In 2017 and 2018, CMS sent 24,000 letters to Medicare physicians who were prescribing higher than average levels of opioids to encourage safe prescribing practices. Additionally, physicians who abuse their prescribing privileges are excluded from Medicare and Medicaid reimbursement. Aside from the potential benefits these efforts could have in reducing abuse, reducing the frequency in which opioids are prescribed could significantly reduce the average costs of MSAs going forward. Based upon a recent case study we conducted, there was a proportionate decrease in the average MSA amount and the percentage of MSAs including opioid medications.

Another trend to watch is the expansion of alternative treatments. CMS is considering extending Medicare coverage to some alternate forms of treatment not currently covered by Medicare to encourage the use of these treatments first. Although no specifics have been provided, we will be monitoring Medicare coverage decisions to keep you informed of changes.

In cases where individuals are prescribed opioid medications, CMS has discussed increased utilization of the prescription medication naloxone used to treat an overdose. We have seen CMS require this medication in Medicare Set-asides more frequently in recent months and expect this trend to continue. HHS has discussed the possibility of an over-the-counter version of this medication being produced in the near future.

Given the trend toward alternative treatments, now may be the perfect time to re-evaluate the future treatment needs of claimants who are currently prescribed opioid medications. Now more than ever, physicians are encouraged to consider other methods for treating claimant’s pain. We would be happy to help you review a claimant’s treatment plan in order to determine if alternates to opioid medication may be an option in your cases.

#opioidepidemic #CMS #MSA #naloxone #Medicare #Medicaid #HHS #MedicareCompliance

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