Category Archives: Medicare Secondary Payer (MSP)

Medicare Secondary Payer (MSP)

Medicare Secondary Payer Recovery Portal’s Additional Functionality

On 8/16/2018, 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 Medicare Secondary Payer Recovery Portal (MSPRP) is a web-based tool designed to assist in the resolution of liability insurance, no-fault insurance, and workers’ compensation Medicare recovery cases. The MSPRP provides the ability to access and update certain case-specific information online. CMS emphasized benefits of utilizing multi-factor authentication (MFA) to view unmasked and more complete claim details shown on the MSPRP.

Some of the current portal capabilities and developments noted recently in the July 2018 updated MSPRP User Guide include the ability to:

  • See current conditional payment amounts
  • View case information, claim type, case ID number, refund status
  • See correspondence that has been sent and received
  • Request a copy of the Conditional Payment Letter
  • Provide insurer debtors and their authorized recovery agents the option to download electronic conditional payment letters
  • View and dispute pre-demand claims
  • Initiate an initial determination/demand
  • View the decision status of claims
  • Submit appeal requests for redetermination

Here are just some of the upcoming developments anticipated in the future for the portal:

  • Ability to report and establish new workers’ comp, no-fault and liability cases is expected in early 2019
  • Ability to make recovery payments.

The MSP recovery industry and Optum Settlement Solutions, thanks CMS for hearing our suggestions and continuing to modify the portal to make MSP compliance more automated and expeditious. If you have questions or need technical help concerning the MSPRP options accessible, call their help desk at 1-855-798-2627, rather than the BCRC and CRC.

As always, Optum Settlement Solutions stands ready to assist any of our current or potential clients with any conditional payment issue, including any questions or concerns pertaining to the latest announcements made by CMS on the MSPRP additional functionalities.

For more info, see http://go.cms.gov/msprp.

The Optum Clinical Team Can Help You Move Your Claims to Settlement

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. Part of our approach is monitoring RED BOOK® Average Wholesale Price (AWP) for the most common medications present in (WCMSA) arrangements. Through this process, we identify price adjustments which positively or negatively affect the WCMSA.

In the month of July we saw price increases for Vesicare® tablets (used in the treatment of bladder conditions) and Gralise® tablets (gabapentin extended release for neuropathic pain). There was a price decrease for hydromorphone extended release tablets (long-acting opioid for chronic pain).

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

Product name NDC code Dosage form

Strength

AWP unit price
reduction/increase
Hydromorphone 13811070110 ER Tablets

8 mg

-$5.85

Hydromorphone 13811070210 ER Tablets

12 mg

-$7.20

Hydromorphone 13811070310 ER Tablets

16 mg

-$9.60

Hydromorphone 13811070410 ER Tablets

32 mg

-$19.20

Gralise 13913000419 Tablets

300 mg

$0.92

Gralise 13913000519 Tablets

600 mg

$0.92

Vesicare 51248015052 Tablets

5 mg

$0.82

Vesicare 51248015103 Tablets

10 mg

$0.82

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. If you have a WCMSA with hydromorphone ER tablets you will immediately benefit from a reduction in the cost of this medication. In some cases, this may make settlement a viable option.

Optum will proactively contact clients when we have previously completed a WCMSA where these medications are prescribed. It is our recommendation that carriers, TPA’s and claim handlers review cases to determine if price changes positively impact settlement options.

Optum has clinical intervention products available, which may help mitigate costs and improve patient outcomes through more suitable clinical alternatives and cost effective therapeutic equivalents. We will continue to inform the industry of AWP pricing and other changes that may affect WCMSA arrangements.

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.

New WCRC, Capitol Bridge: Changes and Trends

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.

In addition to the above, Optum has found the turn around time for completed  WCRC determinations has increased from 9 days to 20 days.  Hopefully this is just a slow down due to the transition and will level out in the near future.

There have been several “hearing loss” cases which have been returned with counter high allocations for future office visits and additional audiograms over the claimant’s life expectancy.  Since Medicare does not cover ongoing office visits or testing once the claimant has been diagnosed with simple hearing loss (no other ear conditions noted), “hearing loss” claims have historically been approved as Zero MSA allocations.  Optum is currently resubmitting these cases for additional review and reconsideration of a Zero MSA allocation due to the error of inclusion of non-Medicare covered items/services.

The above changes appear to be due to the transition to the new contractor and should be temporary.  It was expected that there would be a short adjustment period as a result of the transition.   Optum will continue to report any additional trends we become aware of that will affect WCMSAs in an ongoing effort to keep our clients apprised of changes as they occur.