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Settlement Solutions

A smarter, clinically-appropriate way to achieve Medicare secondary payer compliance and cost savings

Early identification and intervention results in more than $51M+ in savings and safer, more effective, care for claimants.

Evidence shows that performing a clinical review earlier in the life of a claim leads to significant positive impact to the overall cost of the claim, without sacrificing the claimant’s future care or Medicare Secondary Payer (MSP) compliance status.

On average, Optum saves $110K over the lifetime of a claim simply by doing what we do best with our early-intervention program. It starts with the Part D detector, which identifies opportunities for pharmacy costs to be mitigated for Medicare Set-Aside (MSA) purposes. Our clinical pharmacists and nurses review treatment plans to provide actionable plans to reduce MSA exposure. Next, we utilize our peer-to-peer outreach and nurse monitoring to review therapies which could prevent the claim from settling altogether. Finally, a cross functional team reviews all aspects of the case to project future care spending for the MSA, and by not waiting until the time of settlement to implement these recommendations, we also avoid delaying claim resolution.

Timely, accurate Section 111 reporting impacts Conditional Payments and MSA Allocations

Previously, Section 111 reporting has been focused on the looming potential fines of up to $1,000 per day, per claim penalty, for not timely reporting accurate information to Medicare. However, the more practical and present effect of poor or late data has really impacted the industry as seen through the increase in the number of Conditional Payment demands and counter high MSA allocations. The Optum MedicareConnectSM portal has a 100 % acceptance rate and has built-in tools that help ensure clean and accurate data is reported to Medicare.

Collaborative consultation results in the lowest defensible allocation with savings over $15.3M

Since the inception of the MSA process, Optum has led the way by sharing our experience and knowledge with our clients with every MSA completed. By leveraging technology and taking a consultative approach, we have consistently achieved a CMS (Centers for Medicare & Medicaid Services) first pass acceptance rate of 82%. Whether the claim was part of our early-intervention program or not, Optum applies our consultative approach that brings pharmacy, medical claims and legal expertise together to review appropriateness of care and mitigation opportunities. As a result, we have identified and implemented an additional $15.3 million in savings for our clients while preparing MSA allocations. By working with us, you can expect industry-leading settlement services providing lower costs through accurate, defensible MSA allocations.

Persuasively negotiating payments saves more than $18.7M

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The Basics of Conditional Payments

Negotiating from a position of strength, Optum provides unparalleled access to data combined with well qualified clinical expertise in MSP compliance. Our negotiation success rate for Conditional Payments is 94% with an average negotiated savings of 97%, representing savings of more than $18.7 million. We also help our clients navigate the CMS dispute and appeals process by reviewing disputable charges and providing recommendations for resolution and reduction. More importantly, our legal compliance team is dedicated to proactively resolve Conditional Payment matters for our clients.

Impact of the PAID Act on Workers’ Comp, No-Fault and Liability Claims

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Compliance or cost savings? You can have both.

By working with Optum, you can expect industry-leading settlement solutions and insight at competitive prices and with, perhaps more importantly, no surprises to you or the claimants you serve. Our services are available individually, grouped together or often sought out in a complete package for an end-to-end solution. You don’t have to choose between compliance and cost savings. Choose both. Choose Optum.

For more information, please contact expectmore@optum.com.