NCIC Opioid Prescribing Rules Practical Effects Current Status of Medical Marijuana in NC Scarlette Gardner, Esq. & Melissa K. Walker, Esq. June 16, 2018 Current NC WC Opioid Prescribing Legal Requirements 1. NCMB Position 2. NC Session Law 2017-74 Statement: “STOP” Act CDC Guidelines 3. NCIC Rules For The Utilization Of Opioids, Related Prescriptions, And Pain Management Treatment In Workers' Compensation Claims NC STOP Act provisions Applies to outpatient prescriptions only: • No more than 5 days opioid supply upon initial consultation and treatment for acute pain. • No more than 7 days opioid supply immediately following surgery. • Upon subsequent consultation for same pain, practitioners may issue any appropriate renewal, refill, or new prescription for targeted controlled substance (TCS) i.e. Schedule 2 or 3 opioid. 3 1
NCIC Opioid Rules Go to NCIC website at www.ic.nc.gov to obtain: 1. Adopted administrative rules 2. NCIC Companion Guide 3. NCIC Chart: “Basics of the phases of treatment under the Opioid Utilization Rules (.200 Rules) 4 NCIC Opioid Task Force Guiding Principles 1. Attract and retain highly skilled medical providers for WC treatment. Give prescribers a “legal” reason for refusal to 2. continue opioid therapy. 3. INCENTIVIZE short-term opioid prescribing. 4. DETER long-term opioid prescribing via prescribing requirements and payer authorization discretion. 5. Promote non-pharmacological and non-opioid treatment alternatives for pain relief. 5 IMPORTANT NOTE!!! • No objection letters were filed with Rules Review Commission. • Thus, Rules were not forwarded to General Assembly for review which may have resulted in long delayed implementation and enactment of new laws disadvantageous to payers. 6 2
NCIC’s Stated Purposes of Rules 1. Rules DO NOT constitute medical advice or standard of care. 2. Rules address OUTPATIENT utilization of opioids, related prescriptions, and pain management treatment for non-cancer pain. 3. Rules help ensure employees receive medical care intended by Chapter 97 and costs are contained. 7 Practical Effects of Rules What this means for individual claims? 1. Rules create: a. Reasonable prescriber hassle factor. b. Sufficient payer authorization roadblocks to slow down opioid therapy. 2. Rules allow payer flexibility: a. Payers may “pump the brakes” by refusing opioid authorization when prescribers do not adhere to Rules requirements. b. Payers may authorize opioid therapy outside Rules when they deem appopriate. 8 Applicability of Rules • Rules DO NOT APPLY to prescriptions issued by non- workers’ compensation prescribers. •Workers’ compensation patients may be prescribed anything by other prescribers simultaneously treating them. 9 3
Applicability of .200 Rules Date of first TCS prescription (Targeted Controlled Substance - Schedule 2 or 3 opioid) MUST BE May 2, 2018 or after for .200 Rules to apply. 10 Applicability of .200 Rules EXEMPTION: WC patients who received TCS treatment more than 12 consecutive weeks immediately before May 1, 2018 i.e. first TCS prescription on or before February 5, 2018. 11 .200 Rules - 2 Pain “Phases” Acute Phase: 12 weeks of treatment for pain following an injury by accident, occupational disease, surgery for an injury, or subsequent aggravation of an injury. There may be multiple “acute phases” during a claim. Chronic Phase: Continued treatment for pain immediately following a 12 week period of treatment using a targeted controlled substance “TCS”. DIFFERENT RULES APPLY TO TCS PRESCRIPTIONS IN EACH PHASE. 12 4
Applicability of .300, .400, .500 Rules .300, .400, .500 Rules apply to ALL TCS prescriptions: 1. Co-prescribing naloxone. 2. Referral for non-pharmacological treatment. 3. Referral for opioid tapering/ substance abuse disorder assessment/treatment. 13 What is the role of Nurse Case Managers? • Nurse case managers may provide general, non patient specific information to medical providers regarding existence and content of the Rules. • Nurse case managers may give medical providers and employees documents published on NCIC website: ic.nc.gov • Nurse case managers may not provide opinions to medical providers regarding whether TCS treatment does or does not comply with the Rules. • Nurse may give notice to prescriber and employee of potential issues with payer authorization of prescription. 14 Payer Options REMEMBER: Rules address prescribing requirements for medical providers, not payers. • Payers may or may not authorize TCS prescriptions that do not meet the Rules’ prescribing requirements. • Payers requiring adherence to all Rules provides ability to put the brakes on TCS treatment. 15 5
Payer Options Payer Prescription Denial Options • Payer may immediately authorize retail pharmacy dispensing of dosages up to the Rules’ limits so that patient goes home with some pain relief medication. • Payer may authorize treatment outside of Rules based on medical documentation and communication with prescriber. 16 Payer Options Other Payer Options To Combat Noncompliant Opioid Prescribing • Request written “medication review” i.e. a peer review of all WC related medications prescribed by all authorized treating physicians. • Exercise NCGS § 97-25 right to direct medical treatment elsewhere i.e. change authorized treating physicians if unhappy with prescriber’s nonadherence to the Rules. 17 What happens if a payer refuses to authorize a prescription? IMPORTANT POINTS!!! • Medical providers will ALWAYS get paid for services rendered. • Payers MAY NOT refuse to pay for a medical visit/treatment if medical provider writes a prescription that is not authorized by payer. 18 6
What happens if a payer refuses to authorize a prescription? Parties are encouraged to request information, communicate in detail, and reach agreement on an alternate course of treatment. IF THAT DOES NOT WORK.... 19 What if employee files a medical motion related to the Rules? Rules allow employee to file NCGS § 97-25 medical motion if disputes cannot be resolved by the parties: NCIC will rule based upon the following factors: (1) The necessity of a waiver; (2) The party's responsibility for the conditions creating the need for a waiver; (3) The party's prior requests for a waiver; (4) The precedential value of such a waiver; (5) Notice to and opposition by the opposing parties; and (6) The harm to the party if the waiver is not granted. 20 2 prongs of evidence supporting opioid therapy denial Legal Arguments • TCS prescription exceeds MED limit. • Medical records fail to show prescriber compliance with .200 Rules: a. Periodic urinary drug testing (UDT). b. Use of Opioid Risk Assessment Tool. c. No documentation of NC CSRS checks (effective 11/1/2018 or sooner). d. No documentation non-opioid, non- pharmacological therapy is not appropriate. e. Type/number of TCS (short and long-acting). • Payer has attempted to compromise with patient regarding pain treatment. 21 7
2 prongs of evidence supporting opioid therapy denial Patient Safety & Well-Being Arguments • Non-opioid meds or therapies have not been tried. • Long-term opioid therapy has not improved function. • Overall pharmacy risk due to potential interaction with other drugs. • Limited or no objective physical findings supporting subjective pain reports. • History of opioid overdose/naloxone use. • Prior attempt(s) to change authorized treating physician (ATP) were rejected. • Prior attempt(s) to obtain medication review were rejected or results ignored. 22 Important Legal Distinction!!! • Chronic pain is not a separate injury/ condition that must be accepted or denied, it is merely treatment for already accepted body parts/conditions. • Chronic pain treatment with any provider type does not create a presumption that a separate mental injury/condition exists. 23 Cost Containment/Risk Management Strategies 1. Advise payers to require PBM implement NC STOP Act and Rules requirements in prescription approval algorithms. 2. Advise payers to get list of claims with >90 MED scores and closely monitor their medical records for prescriber compliance with Rules. 3. Advise payers to direct or transfer care to physicians that comply with Rules (especially pain management) and try other pain therapies before opioids. 4. Advise payers authorizing non-pharmacological treatment in lieu of opioid therapy to initially authorize same amount of visits as usual for such therapies to avoid potential medical motions. 24 8
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