Main-blog-page-header

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



  • Despite settlement agreement, primary payer receives request for reimbursement

    by
    | May 15, 2019
    Tag Icon
    Medicare Insights
    On August 6, 2018, in the United States District Court for the District of South Carolina, Florence Division, Humana Insurance Company (Humana) brought an action against Bi-Lo, LLC (Defendant), a Delaware limited liability company that sells groceries in the southeastern region of the United States. Humana’s action is for declaratory judgment to recover double damages pursuant the Medicare Secondary Payer Act (MSP) in the amount of $32,754.02 due and owing to Humana, as a Medicare Advantage Organization (MAO), by virtue of payments made on behalf of one of its enrollees, a Medicare beneficiary who elected Medicare Advantage coverage from Humana. This occurred despite the existence of a settlement agreement in which the enrollee and her counsel agreed to be responsible for such reimbursement. However, because the enrollee/counsel did not reimburse the Medicare payments advanced by Humana, Humana again seeks reimbursement from the Corporate Defendant.


  • Thank you for your trust and confidence in Our Settlement Solutions Team

    by
    | May 15, 2019
    Tag Icon
    Settlement Solutions
    As we take a couple of days to reflect on our lives, the folks in our lives, and the significance and meaningfulness of those individuals in our lives, on behalf of Optum, I wanted to take this opportunity to say thank you for your trust and confidence in our Settlement Solutions team.


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

    by
    | May 15, 2019
    Tag Icon
    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

    by
    | May 15, 2019
    Tag Icon
    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

    by
    | May 15, 2019
    Tag Icon
    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

    by
    | May 15, 2019
    Tag Icon
    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

    by
    | May 15, 2019
    Tag Icon
    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.



Stay informed by receiving latest updates

Do you have a question about a blog post?