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 Releases Update to WCMSA Reference Guide

The Centers for Medicare and Medicaid Services (CMS) released an update to their Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (version 2.7) with two changes. To view the reference guide, click here.

  1. Section 14.0 (page 51), Appendix 1 and Appendix 5: This update provides the new Workers’ Compensation Contractor (WCRC) phone number: 833-295-3773 and hours of business, 9 a.m.–5 p.m. EST, Monday–Friday.
  2. The Confidentiality Statement now states the Medicare beneficiary must provide a written request or explicit written consent/authorization for a party to obtain information from CMS regarding the Medicare beneficiary.

As indicated by CMS in their March 7, 2018 teleconference, Capitol Bridge is the new WCRC. No material changes were made to the reference guide related to the WCMSA review process.  Please continue to watch this site for additional updates, news or trends from CMS.

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

Strength

AWP Unit Price Reduction

Bupropion Hydrochloride

00781-5528-31

TER

150 mg

$3.92

Bupropion Hydrochloride

00781-5529-31

TER

300 mg

$2.24

Diclofenac Sodium

61145-0102-12

ECT

75 mg

$0.51

Buprenorphine Hydrochloride/Naloxone Hydrochloride

00406-8020-03

SL TAB

8/2 mg

$0.34

Clonazepam

00781-8018-05

TAB

0.5 mg

$0.11

Diclofenac Sodium

61145-0101-18

ECT

50 mg

$0.10

Quetiapine Fumarate

00904-6639-61

TAB

50 mg

$0.09

Tramadol Hydrochloride

68094-0017-61

TAB

50 mg

$0.06

Methadone Hydrochloride

66689-0898-40

TBS

40 mg

$0.04

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
Email: wcrc@capitolbridgeLLC.com
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.