Category Archives: News Bulletins

CMS issues WCMSA Reference Guide Version 2.8

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). The notable changes are as follows:

  1. As required by Section 501 of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015, CMS will discontinue all Social Security Number (SSN)-based Medicare identifiers and distribute a new 11-byte Medicare Beneficiary Identifier (MBI)-based card to each Medicare beneficiary by April 2019. All fields formerly labeled as Health Insurance Claim Number (HICN) are now labeled as “Medicare ID” and can accept either a HICN or the new MBI.
    • Page 3 of the WCMSA Reference Guide refers to this update when contacting the Benefits Coordination & Recovery Center (BCRC) to confirm the injured person’s Medicare ID (HICN, MBI or SSN).
    • Page 33, under Section 05 – Cover Letter (WCMSA submission letter) indicates: Claimant’s Medicare ID (HICN or MBI) as displayed on their Medicare card or their SSN, if not yet entitled to Medicare, is required in the submission.
    • Page 63, Appendix 2: The Abbreviations List now includes MBI – Medicare Beneficiary Identifier.
    • Page 67, an update to the definition of Social Security Number: The SSN is an identification number issued by the Social Security Administration and used instead of a Medicare ID (HICN or MBI) when the Medicare ID is not present.
    • All of the sample letters found in Appendix 5 change SSN or HICN to Medicare ID or Medicare ID/SSN.
  2. An updated link to the CDC Life Expectancy Table is located on page 41 under Section 10.3, number 7: https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_04.pdf
  3. An update to the jurisdiction and calculation method for medical reviews (Table 9-1 and Table 9-2):
    • Table 9-1 added one additional scenario in its order of precedence, number 6, stating: If the WC carrier’s attorney does not have an address in the state in which the WC claim was filed, then the pricing will be based on the zip code of the injury address.
    • Table 9-2 is a completely new table for the WCMSA Reference Guide.
      • If a case is filed with the U.S. Department of Labor Office of Workers’ Compensation Programs (OWCP); pricing is based using the OWCP Fee schedule
      • If submitted documentation indicates that a proposed WCMSA amount is based upon a Longshore Harbor Workers’ Compensation Act settlement; pricing is based on the OWCP fee schedule for the zip code of claimant’s residence, unless the submitter specifies actual charges
      • If a state WC fee schedule does not exist based on the jurisdiction evaluation above (Indiana, Iowa, Missouri, New Jersey, Virginia, and Wisconsin); Pricing is based using actual charges, even if the submitter proposed the use of a fee schedule
      • If a state WC fee schedule exists based on the jurisdiction evaluation above; Pricing is based on the most current version of the fee schedule posted publicly

As an established Medicare Secondary Payer compliance services provider in auto, liability, no-fault and workers compensation claims, Optum Settlement Solutions remains the leader in providing accurate and affordable mandatory insurer reporting, conditional payments resolution and set aside allocations, approval and administration services.
As always, we will continue to update the property and casualty insurance industry with news, trends or additional updates from CMS and the WCRC.

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.