MSA Clinical Review

Containing pharmaceutical costs and driving MSA savings

An MSA Clinical Review from ISO Claims Partners is an analysis of the pharmaceutical costs associated with a Medicare Set-Aside (MSA) case. The review defines — in collaboration with the treating physicians — the appropriate current and long-term pharmaceutical regimen, with a special focus on narcotics.


Historically, Centers for Medicare and Medicaid Services (CMS) allocations for pharmaceutical costs in an MSA have not always been based on an assessment of clinical appropriateness. In such cases, the payer can be responsible for disproportionately allocated drug costs embedded in the MSA settlement. While CMS may accept off-label use of drugs — or may consider discontinuing a particular drug for future allocations — the payer must present specific and adequate proof of the clinical appropriateness of such a change.

The MSA Clinical Review provides such proof by recommending regimen changes and working with treating physicians to determine appropriate treatment modifications. The MSA Clinical Review also ensures adherence through documentation of the altered regimen over time.

How it works

ISO Claims Partners and PRIUM — a leading provider of medical cost management services — have formed a strategic alliance to help you manage pharmaceutical costs in an MSA.

To give CMS the necessary proof of the discontinuance of any prescription drugs, the MSA Clinical Review uses a three-step process. We recommend that you not submit an MSA to CMS until the entire process is complete. The three steps are:

  1. Discussion: PRIUM’s active-practice physician initiates collegial and professional discussions with all prescribing physicians involved in the case. The conversations focus on the physicians’ roles in determining the claimant’s drug regimen. PRIUM works with the prescribing physicians on modifications to the regimen and attempts to secure written acknowledgment of any agreement. The MSA Clinical Review final report details the full recommendations, how they relate to evidence-based medicine (EBM), and responses from the prescribing physicians.
  2. Enforcement: Upon written approval from the claims adjuster, PRIUM implements a customized formulary requiring prior authorization for all drugs that the MSA Clinical Review found inappropriate or unrelated. Ideally, the parties will agree to add the claimant to PRIUM’s Pharmacy Benefit Management (PBM) program for complete transparency of prescribing behavior.
  3. Oversight: PRIUM’s Coordinated Oversight group continually monitors the drug transactions during the period of weaning and discontinuance. PRIUM contacts the prescribing physician’s office periodically to get progress reports on the modified treatment plan. That typically continues until the physician has fully implemented the recommendations or until your representative is satisfied with the progress.

When to order an MSA Clinical Review

You may want to order an MSA Clinical Review for cases involving one or more of these triggers:

  • settlement stalemate (an MSA settlement calculation too high to proceed)
  • drugs including acetaminophen (APAP) with aggregate dosage exceeding 4,000 mg/day
  • opioids or narcotics used for more than six consecutive months with an aggregate dosage exceeding 120 mg morphine equivalent dose (MED)/day or still used three or more years after the injury
  • muscle relaxants used for more than two consecutive months or still used three or more years after the injury
  • NSAIDs used for more than six consecutive months with an aggregate dosage exceeding 3,200 mg/day or still used three or more years after the injury
  • any antinarcoleptic drug without a narcolepsy diagnosis
  • any topical analgesics
  • any compound medications
  • a monthly aggregate drug spend exceeding $1,000
  • outstanding medical questions leaving the patient at less than maximum medical improvement (MMI)
  • multiple prescribing physicians

For more information about ISO Claims Partners Medicare compliance services

Representatives are available Monday through Friday, 9 a.m. through 8:30 p.m. Eastern time.