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Sharing perspectives leads to greater understanding and fuels innovation. The ​Optum Insights ​blog is where we share our perspective and challenge preconceptions to clear a new path forward



  • Is it just me or are we all thinking the same thing? Is this the beginning of mandatory MSAs in liability, no-fault, work comp claims?

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    • Optum for Workers' Compensation
    | May 16, 2019
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    Workers' Compensation, MSA, Medicare Insights

    April 22, 2019 
    by Rafael Gonzalez, Esq.

    Late in 2018, our federal government announced in 2019 that it intends to regulate how and when to take Medicare’s future interests into account.

    Time may be up on “MSA not necessary” assumption
    You have heard it a million times: Medicare Set Asides (MSA) are not required. You have been told again and again, there is no law that requires submission of MSAs to the Centers for Medicare and Medicaid Services (CMS) for review and approval. Well, both of these statements may come to an abrupt end if, as announced, the federal government produces Code of Federal Regulations (CFR) to ensure that beneficiaries and payers meet future medical obligations under the Medicare Secondary Payer Act (MSP).

    Non-submit MSAs—likely triggering new regulations
    Involved in the MSP program since 1983, I had a feeling this moment was coming. And, as the industry’s appetite for non-submit MSAs has grown, I began to write and speak publicly about the potential that such behavior would, in fact, encourage or push the federal government into mandatory regulatory mode.

    Federal actions foretell changes ahead
    The latest announcement by the Executive Office of the President and the expected efforts HHS/CMS will undertake in 2019 and beyond certainly seem to indicate this will be the beginning of a new course for payers as well as current and anticipated Medicare beneficiaries. These federal actions may mandate the creation of MSAs in auto, liability, no-fault, and work comp claims, and possibly require submission of such MSAs to CMS for review and approval.

    No legal requirement to produce or submit MSAs, but…
    As we have learned since 2001, a current/potential Medicare beneficiary may, but is not legally required to, consider Medicare’s future interests by putting together an MSA and seeking CMS approval of the proposed MSA amount. The primary benefit for doing so has been the certainty of CMS reviewing and approving the proposed amount with respect to the sum that must be appropriately exhausted before Medicare becomes the primary payer for future claim related medical expenses.

    How we got here
    When the Medicare program was enacted in 1965, Medicare was the primary payer for all services, with the exception of those covered and payable by workers’ compensation. In 1980, Congress enacted the first of a series of provisions.....



  • Answers to Your Most Common Questions about Predictive Analytics in Workers’ Comp

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    • Optum for Workers' Compensation
    | May 16, 2019
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    Analytics, Workers Comp, Clinical, Predictive Analytics
    Predictive analytics improve clinical outcomes and reduce costs for payers, but only if used properly. Risk & Insurance interviewed OWCA experts to learn how to apply predictive analytics in workers' compensation.


  • Medicare Secondary Payer Recovery Portal enhancements ease payment process

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    | May 16, 2019
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    Medicare Secondary Payer, Medicare Insights
    Enhancements to the Medicare Secondary Payer Recovery Portal (MSPRP) have been announced by CMS that address electronic payment capabilities for identified Non-Group Health Plan (NGHP) conditional payment debt. CMS publicized the enhancements during a March 13, 2019, webinar.


  • What you need to know about naloxone

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    | May 16, 2019
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    Evzio, Naloxone, Opioids, Medicare Insights
    Naloxone is an opioid antagonist that displaces opioids from receptors in the brain, reversing the effects of opioid analgesics, including their life-threatening effects. Naloxone is commercially available by nasal spray (i.e., Narcan® Nasal Spray), solution for injection and an auto-injector (i.e., Evzio®). Currently, naloxone products are only available by prescription. Naloxone is not a controlled substance and has no abuse potential. It has no direct role in the treatment of pain or other industrial conditions; it is used exclusively for the treatment of a known or suspected opioid overdose.


  • Changes influencing Medicare Secondary Payer compliance go into effect April 1, 2019

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    | May 16, 2019
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    Medicare Secondary Payer, Medicare Insights
    In accordance with the SSN Fraud Prevention Act of 2017, the COB&R program will mask the SSN and SSN-portion of the HICN, on all outgoing letters as of April 1, 2019.


  • Brand medication increases and generics for release in 2019

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    | May 15, 2019
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    Medicare Secondary Payer, Generics, Medicare Insights, medicareinsights blog
    As an established Medicare Secondary Payer (MSP) compliance services provider, one of our goals is to keep clients, and the property and casualty insurance industry, informed of changes affecting MSP compliance and Workers’ Compensation Medicare Set Asides (WCMSAs). As part of our best business practices, we continually monitor the RED BOOK® Average Wholesale Price (AWP) changes of the most common medications in WCMSAs as well as generic medications that come to market. This practice assists in identifying price changes that affect WCMSAs.


  • CMS releases NGHP Section 111 User Guide Version 5.5

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    | May 15, 2019
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    Medicare Insights, CMS
    As an established Medicare Secondary Payer (MSP) 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 January 4, 2019, CMS released an updated Non Group Health Plan (NGHP) User Guide, version number 5.5.



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