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



  • MAP and PDP private cause of action suits not just a fad

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    | May 15, 2019
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    Medicare Secondary Payer, MSA, Medicare Insights
    If you are keeping up with Medicare Secondary Payer (MSP) trends and updates, then you know that Medicare Advantage Plans (MAPs) and Prescription Drug Plans (PDPs) private cause of action suits continue to be the rage, with case law arising in federal district and circuit courts across the country. When you add the recent announcement from the Centers for Medicare & Medicaid Services (CMS) that Medicare Advantage premiums will decline while plan choices and new benefits increase, it’s no wonder enrollment is projected to reach a new all-time high with more than 36 percent of Medicare beneficiaries expected to be enrolled in Medicare Advantage in 2019. With more Medicare beneficiaries switching from Medicare Parts A and B traditional coverage to Part C Medicare Advantage coverage, more and more of these MAPs will be providing your insured, and therefore your potential claimants, with Medicare benefits related to your claim. So, if you thought MAP and PDPs’ Medicare Secondary Payer private causes of action were a fad, think again.


  • Trends affecting workers’ compensation Medicare Set-Aside allocations

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    | May 15, 2019
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    Medicare Set-Aside, Medicare Insights
    Capitol Bridge, LLC, the newest Workers’ Compensation Review Contractor (WCRC) for the Centers for Medicare and Medicaid Services (CMS), officially took over on March 19, 2018. Since that time, the Medicare Set-Aside (MSA) industry has noticed aggressive changes in the Workers’ Compensation Medicare Set-Aside (WCMSA) review process, resulting in an increase in WCMSA allocations.


  • CMS releases NGHP Section 111 user guide version 5.4

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    | May 15, 2019
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    CMS, Medicare Insights
    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 October 1, 2018, CMS released an updated Non Group Health Plan (NGHP) User Guide, version number 5.4. T


  • CMS issues WCMSA Reference Guide Version 2.8

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    | May 15, 2019
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    WCMSA, CMS, Medicare Insights
    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).


  • WCMSA Alert! CMS is now including Lyrica® in your WCMSAs

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    | May 15, 2019
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    WCMSA, CMS, Medicare Insights, Lyrica
    Gabapentinoids like gabapentin (Neurontin) and pregabalin (Lyrica®), utilized as “off-label” in workers’ compensation claims for lumbar radicular pain, had not initially been made part of an approved WCMSA. Since early 2011, the WCRC was including gabapentin in a WCMSA allocation for radicular pain, but Lyrica continued to be excluded, making it clear that Lyrica was considered off-label for lumbar radiculopathy without spinal cord injury―at least until September 2018, when the WCRC began to add Lyrica to MSA allocations despite being used to treat an “off-label” neuropathic pain.


  • Medicare Secondary Payer recovery portal’s additional functionality

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    | May 15, 2019
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    Medicare Secondary Payer, CMS, Medicare Insights
    On August 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 Optum clinical team can help you move your claims to settlement

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    | May 15, 2019
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    WCMSA, AWP, Medicare Insights
    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.



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