A Formal Review Program for Liability/No Fault MSAs Is Back

As anticipated, implementation of a formal voluntary Liability Medicare Set-Aside (LMSA) and No-Fault Medicare Set-Aside (NFMSA) review program is at the forefront once again. A proposed rulemaking,  Miscellaneous Medicare Secondary Payer Clarifications and Updates, has been posted by the Office of Management and Budget, which states that A Notice of Proposed Rulemaking (NPRM) will be issued by September 2019.

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Lyrica® generic delayed until summer 2019 and Pfizer to increase drug prices

This is a cross-post from our Optum Insights blog. The U.S. Food and Drug Administration’s (FDA) recent decision to grant pediatric exclusivity for Lyrica® ― as it may be used as an adjunctive therapy for partial onset seizures in pediatric epilepsy patients ― extends the period of market exclusivity in the U.S. by an additional … Read moreLyrica® generic delayed until summer 2019 and Pfizer to increase drug prices

Physical trauma-based NGHP reporting threshold remains at $750 in 2019

As required by section 1862(b) of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) has reviewed the costs related to collecting Medicare’s conditional payments and compared this to recovery amounts. The full report, released November 15, 2018, is available here. As a result of the computation, the threshold for physical trauma-based liability insurance settlements will remain at $750 in 2019.

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Despite settlement agreement, primary payer receives request for reimbursement

On August 6, 2018, in the United States District Court for the District of South Carolina, Florence Division, Humana Insurance Company (Humana) brought an action against Bi-Lo, LLC (Defendant), a Delaware limited liability company that sells groceries in the southeastern region of the United States. Humana’s action is for declaratory judgment to recover double damages pursuant the Medicare Secondary Payer Act (MSP) in the amount of $32,754.02 due and owing to Humana, as a Medicare Advantage Organization (MAO), by virtue of payments made on behalf of one of its enrollees, a Medicare beneficiary who elected Medicare Advantage coverage from Humana. This occurred despite the existence of a settlement agreement in which the enrollee and her counsel agreed to be responsible for such reimbursement. However, because the enrollee/counsel did not reimburse the Medicare payments advanced by Humana, Humana again seeks reimbursement from the Corporate Defendant.

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