Category Archives: News Bulletins

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 February brought price drops of the following medications:

  • buprenorphine/naloxone (Suboxone®) commonly prescribed for opioid dependence
  • diclofenac (Voltaren®) in multiple strengths used to treat pain
  • methadone (Dolophine®) commonly prescribed for detoxification or pain management
  • bupropion (Wellbutrin®) in multiple strengths prescribed for depression
  • clonazepam (Klonopin®) used for anxiety or panic disorders
  • quetiapine (Seroquel®) commonly used to treat bipolar disorder, depression or schizophrenia
  • tramadol (Ultram®) used to treat 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


AWP Unit Price Reduction

Bupropion Hydrochloride



150 mg


Bupropion Hydrochloride



300 mg


Diclofenac Sodium



75 mg


Buprenorphine Hydrochloride/Naloxone Hydrochloride



8/2 mg





0.5 mg


Diclofenac Sodium



50 mg


Quetiapine Fumarate



50 mg


Tramadol Hydrochloride



50 mg


Methadone Hydrochloride



40 mg


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.

WCRC contractor transition webinar held with The Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) held a webinar on March 7, 2018, to introduce Capitol Bridge, LLC, our new WCRC contractor, and review the transition plan.

John Jenkins of CMS and Holly Havens of Capitol Bridge discussed the transition between the two WCRC contractors—the incumbent, Provider Resources, LLC, and Capitol Bridge. The last day for Provider Resources will be March 16, 2018, with Capitol Bridge beginning March 19, 2018. The transition will occur over the weekend and should not disrupt business or cause a backlog.

During the webinar, Ms. Havens confirmed the following points regarding the transition:

  • Capitol Bridge has 25 years of CMS support experience and is well versed in Medicare Set Asides. Their staff includes nurses and attorneys who are MSCC certified, pharmacists and administrative staff. Additionally, some of the existing Provider Resources WCRC staff are transitioning to Capitol Bridge.
  • There will be no change to quality or timeliness standards
  • After receipt of a submission the turn around time periods will be:
    • 20 days from the receipt of the submission, if the file does not require any further documentation
    • For a file requiring submission of additional information, the turnaround time for completion is 10 days from the receipt of all necessary documentation (a development letter will be sent).

Capitol Bridge’s contact information is:

Phone: 833-295-3773
Fax: 585-425-5390
All correspondence must include a case control number
Operating hours are 9:00 a.m. to 5:00 p.m. eastern time, Monday through Friday

CMS stated that they expect this transition to be seamless. Mr. Jenkins confirmed no changes or updates will occur to the existing WCMSA Reference Guide and other policies and pricing will not be affected.

Optum looks forward to working with Capitol Bridge on WCMSAs, and is hopeful that the transition will be smooth and seamless as indicated. We will monitor the transition beginning March 19 and keep the industry updated on any new events or issues that arise.

Important Change Regarding Medicaid Secondary Payer Claim Compliance

On February 9, 2018 President Trump signed into law a new budget deal. The new law also contained an important change regarding Medicaid Secondary Payer compliance.

What Optum Had Been Anticipating

Optum Settlement Solutions had been anticipating an Oct 1, 2017 effective date for state Medicaid agencies to begin enforcing the Medicaid Secondary Payer Act enacted in Section 202(b) of the Bipartisan Budget Agreement of 2013, referred to as the “Murray-Ryan bill”. The act permitted state Medicaid agencies to recover all payments Medicaid made related to the underlying personal injury claim before settlement. The recovery was to occur regardless of whether the damages/injuries claimed were related to the medical component of damages within a personal injury settlement or third party settlement.

Practically speaking, each state Medicaid agency was entitled to recover proceeds from a personal injury settlement if the Medicaid paid for medical treatment related to the underlying accident, up to the total settlement amount if that was indeed what Medicaid had paid.  Had the federal law not been reversed, some Medicaid recipients may have been left with no money in their pockets after settlement in order for Medicaid to recover money spent.

What Has Changed Overnight

Section 53102 of the Bipartisan Budget Act of 2018 fully
repealed Medicaid’s expanded recovery rights regarding third party, personal injury settlements. The new legislation overturned what had been anticipated for several years.

The new budget permanently repealed the ability of Medicaid to recover up to the total settlement amount. Now Congress has restored the ability of Medicaid recipients to settle third party liability claims. In other words, the recent repeal allows Medicaid recipients to pursue and settle third‐party insurance claims without fear that all of the settlement proceeds will go towards repaying Medicaid.

What This Means for the Claim Handler

Liability insurers and claim handlers are not totally off the hook. Medicaid still has recovery rights in third party liability settlements and Medicaid will still be permitted to recover some of their payments via third party liability units within each state Medicaid agencies. However, the new legislation will improve the ability to settle the claim and removes the need to pay higher settlement amounts because the claim involves a Medicaid recipient.

Claim handlers will still receive notices from Medicaid reminding you not to settle without contacting Medicaid for their recovery demand. However, these rights will be limited based upon the agreement of the parties as to how funds are allocated under the settlement.

Who Deserves Credit

We applaud the Finance Committee Chairman, Orrin Hatch, Senator Rob Portman, as well as the House Energy and Commerce Health Subcommittee Chairman Michael Burgess, and the House and Senate leaders, who have been worked over the last several years to eliminate this provision. The Medicare Advocacy Recovery Coalition (MARC) has been pressing for a reversal for several years. Our thanks to the MARC Chairman, Greg McKenna for staying behind this effort.

What Optum Can Do For You

If you have a claim you would like to settle and are not sure the claimant is a Medicaid recipient, Optum can contact the state Medicaid liability recovery unit and provide them notice of the pending settlement and request an itemization of payments Medicaid has made pertaining to the underlying claim.

If you have a Medicaid demand seeking recovery of medical expenses related to the personal injury claim that includes unrelated treatment for pre-existing or co-morbid conditions, Optum can dispute and negotiate the amount you owe Medicaid.

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:
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:
Conference number: 877-251-0301
Conference ID: 8389587

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