Author Archives: Settlement Solutions

Updated Medicare Secondary Payer Recovery Portal User Guide Released

This post is written by James Martinez of Optum Settlement Solutions.

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.

Noteworthy revisions:

  • §13.1.1 describes a new Letter Activity tab on the Case Information page that will display all correspondence that has been received, or letters that have been sent related to a BCRC or CRC case in one place.  This new functionality provides the user with three choices as to how to view correspondence received and letters sent.  The user has an option to see this information as follows: “all correspondence received and all letters”, “correspondence received” or “letters sent”, thereby better enabling the viewer to follow the progress of the case thereby reducing BCRC and CRC phone calls to check case status.
  • (Table 13-8) Lists the primary diagnosis code in bold font on the Payment Summary Form (PSF) in cases where Medicare Part A claims do not have a HCPCS or DRG code associated with them. When the primary diagnosis code is bolded, the HCPCS/DRG column will be blank.
  • §13.1.5 allows insurers, recovery agents shown on the Tax Identification Number (TIN) reference file, and insurer representatives with a verified Recovery Agent Authorization to request electronic conditional payment letters (eCPLs) for BCRC and CRC insurer-debtor cases so long as logged in using multi-factor authentication process.
  • §8.3.2 was added to help account managers (AMs) to identify which active designees are using the portal or should be deleted when they have long periods of inactivity. The AMs can view the last login date column added to the designee listing page to confirm.

When conditional payment information is unknown or unreliable, settlements are delayed. The minor changes are expected to provide the parties with an accurate case status, specific to the conditional payment recovery claim. Optum Settlement Solutions will review and test the changes and make recommendations as discovery becomes known.

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.