Author Archives: Settlement Solutions

Prescription drug updates may positively affect Medicare Set Aside

As part of our best business practices, we continually monitor RED BOOK®Average Wholesale Price (AWP) of the most common medications present in Workers’ Compensation Medicare Set-Aside (WCMSA) arrangements. This practice assists in identifying price changes positively affecting WCMSAs.

The month of May brought price drops for several different strengths of gabapentin, commonly used to treat neuropathic pain.

The products in the following table have a reduced AWP, confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Product Name NDC Code Dosage Form Strength AWP Unit Price Reduction
Gabapentin 10135-0646-05

 

CAP 400 mg $0.07
Gabapentin 10135-0647-05

 

TAB 600 mg $2.01
Gabapentin 10135-0648-05 TAB 800 mg $0.37

Please note that RED BOOK AWP is subject to change and this pricing is subject to an increase or decrease in the future.  

CMS uses the lowest AWP when reviewing a WCMSA. The lower price of these medications will immediately affect the prescription costs for WCMSAs (both present as well as prior WCMSA’s that have not settled and there is no CMS determination issued). We will contact our clients in reference to previously completed WCMSA’s where these medications have been prescribed. It is our recommendation that carriers, TPAs and claim handlers review cases to determine the benefit from decreased cost of these medications.

Optum will continue to keep the industry informed of changes in AWP pricing, in addition to when generic equivalents enter the market.

Frank Fairchok Rejoins Optum Settlement Solutions

Optum is pleased to announce that Frank Fairchok has recently rejoined the settlement solutions team as vice president of Medicare compliance reporting and development. Frank will be responsible for MedicareConnect, our industry-leading platform for MMSEA Section 111 — Medicare Secondary Payer Mandatory Reporting — for non-group health plans. He will also help drive new product and technology growth for the division.

Frank originally joined Optum in 2010 and was instrumental in launching MedicareConnect. He managed the platform from the start of live reporting with CMS in January of 2011 and quickly brought it to the forefront of the industry with its capability and accuracy.

Frank has 30 years of business experience in the financial, telecom and workers’ compensation industries and holds a Bachelor’s Degree in Technology Management.

CMS Introduces new Commercial Repayment Center (CRC) Contractor in Transition Webinars

Effective February 8, 2018, a new contractor will assume responsibility of the Commercial Repayment Center (CRC) functions. This includes recoveries where another entity had primary payment responsibility under a Group Health Plan arrangement, as well as conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity as the identified debtor.

CMS will be hosting webinars to introduce this new CRC Contractor. The webinars include a brief introduction and presentation, followed by a question and answer session.

Join us for one or both of these information sessions

Group Health Plan information session
January 17, 2018 at 1:00 p.m. EST
Register here: https://engage.vevent.com/rt/cms2~01172018
Conference number: 877-251-0301
Conference ID: 2696839

Non-Group Health Plan information session
January 18, 2018 at 1:00 p.m. EST
Register here: https://engage.vevent.com/rt/cms2~01182018
Conference number: 877-251-0301
Conference ID: 8389587

Please login 15 minutes before the start time due to the large number of participants.

CMS Releases NGHP Section 111 User Guide v5.3

CMS has released an updated NGHP User Guide, version number 5.3. The updates address the new Medicare Beneficiary Identifier (MBI) initiative in the Introduction, Overview and Appendices chapters.

As required by the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015, CMS will be discontinuing all Social Security Number (SSN) based Medicare identifiers and distribute new 11-byte Medicare Beneficiary Identifier (MBI) cards by April 2019. CMS has exempted all Medicare Secondary Payer (MSP) processes from exclusive use of the MBI. Non-Group Health Plan RREs are permitted to continue to report for Section 111 mandatory insurer reporting using: full SSN, Health Insurance Claim Number (HICN), or MBI. Please note, all fields formerly labeled as “HICN” have been relabeled as “Medicare ID” and CMS will be able to accept either a HICN or the new MBI.

Following is a summary of updates appearing in this release:

The Medicare Identifier on Section 111 Response Files

The most current Medicare ID (HICN or MBI) will be returned in the Section 111 response files in the “Medicare ID” field. Consequently, if an RRE submits information with an HICN and the Medicare beneficiary has received their MBI, the MBI will be returned. Otherwise, the most current HICN will be returned. RREs may submit subsequent Section 111 information for this Medicare beneficiary using either the HICN or MBI.

Medicare Identifier on Outgoing Correspondence

As part of the New Medicare Card Project changes, all correspondence from the Benefits Coordination and Recovery Center and Commercial Repayment Center will use the Medicare identifier most recently provided when creating or updating a MSP record. Therefore, if the most recent information received used an HICN, all subsequent issued correspondence will be generated with the HICN as the Medicare ID. If the most recent information received used an MBI, all subsequent issued correspondence will use the MBI as the Medicare ID.

Direct Data Entry (DDE) Users: Claim Searches

Either the MBI or the HICN can be used in the Medicare ID field when searching for claims on the Claim Listing page. All claims that match will display regardless of the Medicare Identifier used to establish the claim.

Retiree Drug Subsidy (RDS) Unsolicited Response Files

RDS Unsolicited Response Files will contain the HICN or MBI in the “Medicare ID” field, as sent by the RDS system (applicable for Group Health Plans only).

General Updates

RREs can use a SSN to query the Health Eligibility Wrapper (HEW) 270/271 query process. The most current Medicare identifier, either HICN or MBI will be returned in the “Medicare ID” field.

The contact protocol for the Section 111 data exchange escalation process (see Section 8.2).

The ICD-10 exclusions for 2018 (see Chapter 5 Appendices, Appendix I and Appendix J).

CMS will continue to review reporting requirements and post any applicable updates in the form of revisions to Alerts and the user guide as necessary.

A consolidated PDF file of all these updates is available upon request. Please email JustRegister@optum.com if you would like to receive a consolidated, searchable file.