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Sharing perspectives leads to greater understanding and fuels innovation. The ​Optum Insights ​blog is where we share our perspective and challenge preconceptions to clear a new path forward



  • CMS issues WCMSA Reference Guide Version 2.8

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    | May 15, 2019
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    WCMSA, CMS, Medicare Insights
    As an established Medicare Secondary Payer compliance services provider, one of our goals is to keep clients and the property and casualty insurance industry informed of changes affecting MSP compliance. On October 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released an update to the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (version 2.8).


  • WCMSA Alert! CMS is now including Lyrica® in your WCMSAs

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    | May 15, 2019
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    WCMSA, CMS, Medicare Insights, Lyrica
    Gabapentinoids like gabapentin (Neurontin) and pregabalin (Lyrica®), utilized as “off-label” in workers’ compensation claims for lumbar radicular pain, had not initially been made part of an approved WCMSA. Since early 2011, the WCRC was including gabapentin in a WCMSA allocation for radicular pain, but Lyrica continued to be excluded, making it clear that Lyrica was considered off-label for lumbar radiculopathy without spinal cord injury―at least until September 2018, when the WCRC began to add Lyrica to MSA allocations despite being used to treat an “off-label” neuropathic pain.


  • Medicare Secondary Payer recovery portal’s additional functionality

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    | May 15, 2019
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    Medicare Secondary Payer, CMS, Medicare Insights
    On August 16, 2018, the Centers for Medicare and Medicaid Services (CMS) held a town hall webinar discussing new and forthcoming functionality of the Medicare Secondary Payer Recovery Portal (MSPRP). This is welcome news to those who deal with Medicare conditional payments daily and shows continuing efforts by CMS to make coordination of benefits and traditional Medicare recovery efforts a one stop self-service for all.


  • The Optum clinical team can help you move your claims to settlement

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    | May 15, 2019
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    WCMSA, AWP, Medicare Insights
    It is common for medications to comprise a large proportion of a Workers’ Compensation Medicare Set-Aside (WCMSA) allocation. Often times the cost of prescription medications can drive up claim costs and prohibit settlement. Clinical interventions that both improve the injured worker’s medication regimen and aid in decreasing costs are tools that Optum provides to assist our clients.


  • Prescription drug price updates that may affect Medicare Set Asides - update July 24, 2018

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    | May 15, 2019
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    WCMSA, AWP, Medicare Set-Aside, Medicare Insights
    To ensure the most accurate Workers’ Compensation Medicare Set-Aside (WCMSA) arrangement, we monitor RED BOOK® Average Wholesale Price (AWP) of the most common medications present in WCMSAs. This practice assists in identifying price changes, which may either positively affect settlement and provide savings, or increases that could hinder the settlement process and increase claims costs. In the month of June, there were price changes for morphine sulfate tablets – both immediate release and extended release—brands MS Contin and Dilaudid, opioids commonly used for chronic pain. Products with price increases are relatively insignificant at less than 10 percent. However, the decreases are greater than 50 percent, and could provide savings on cases where these medications are prescribed.


  • Updated Medicare Secondary Payer recovery portal user guide released

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    | May 15, 2019
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    CMS, Medicare Secondary Payer, Medicare Insights
    On July 2, 2018, the Centers for Medicare and Medicaid Services (CMS) released limited changes in version 4.2 of its Medicare Secondary Payer Recovery Portal (MSPRP) User Guide. This new information aims to provide electronically current and consistent conditional payment information. In addition, the portal information is designed to help settling parties involving Medicare beneficiaries expedite the process.


  • Prescription drug updates may positively affect Medicare Set Aside - update May 2018

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    | May 15, 2019
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    Medicare Insights, WCRC
    Capitol Bridge, LLC assumed the reigns as the new Workers’ Compensation Review Contractor (WCRC) on 3/19/2018. Immediately following the transition to Capitol Bridge, it was noted that they have a different methodology for pricing. This has caused a slight increase in counter low/high determinations as the industry adjusts to the pricing methodology changes.



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