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.
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.
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For your convenience listed below are our Settlement Solutions services. If you would like more information about a particular service click on REQUEST MORE INFO located above each section.
WC MEDICARE SET-ASIDE (MSA)
Our MSA anticipates an amount that will be designated to pay for future related medical and prescription expenses otherwise reimbursable by Medicare when medical benefits or medical expenses are settled. Optum’s MSA allocation is the lowest defensible MSA in the industry. The MSA contains an analysis of the projected amounts based upon the lifetime rated age, is customer specific, and also includes a grid that lays out the non-Medicare covered costs, all within a written comprehensive report.
NON-SUBMIT MEDICARE SET-ASIDE
A Non-Submit MSA may be selected in situations where the settlement does not meet the Centers for Medicare & Medicaid Services (CMS) Work Comp Medicare Set-Aside (WCMSA) review thresholds, or the settling parties have decided not to participate in the voluntary CMS MSA review process. This type of MSA may result in a lower allocation amount than a CMS-approved MSA. This is due to the MSA being case specific and allocated based on medical records, pharmacy history, utilizing the CMS WCMSA Reference Guide until it deviates from known clinical concerns, state statutory or jurisdictional nuances, and/or includes items and services not otherwise reimbursable by Medicare.
LIABILITY MEDICARE SET-ASIDE (LMSA)
Optum’s cross-disciplinary expertise in pharmacy, medical, legal and claims allows us to effectively combine medical and pharmaceutical standards of care, cost effective pricing, as well as application of the distinct legal facets of each liability case.
As part of the review and preparation of the allocation the following items are considered:
- Policy limits
- Comparative negligence
- Elimination of speculative care
- Strict application of off label prescription use
- Weaning of medications and age-related prescription drug contraindications and dosage requirements
- Brand alternatives and patent expirations
- Industry standards of care (American College of Occupational and Environmental Medicine (ACOEM), Evidence Based Medicine (EBM), Official Disability Guidelines (ODG))
- Medicare coverage guidelines
SECOND OPINION MSA
A quality MSA ensures your interests are protected while containing costs. Our experts can re-evaluate a MSA allocation completed by another provider to ensure accuracy and that the lowest defensible allocation has been obtained.
MSA Submission Services
Once Optum has completed the allocation and received a request from the client for CMS approval, Optum will prepare the necessary documentation and proceed with CMS submission.
Optum’s dedicated CMS submission team will review the previously approved MSA and additional information provided to determine if the claim qualifies for an Amended Review and will then revise the MSA allocation and submit the Amended Review with the necessary supporting documentation to CMS for approval.
If the CMS approval comes back at a countered higher amount to the initial recommended MSA, a resubmission for reconsideration may be possible. Although there is no formal appeals process for a reconsideration of an approved MSA, CMS will re-review a file if additional evidence that pre-dates the date of the initial submission is provided.
SUBMISSION OF ANOTHER VENDOR MSA
Optum will review another vendor’s MSA for accuracy, update the allocation, if required, and submit to CMS for approval.
FUTURE MEDICAL COST PROJECTION (FMCP)
An independent medical summary that considers future medical treatments for the claim under review. The FMCP estimates the future medical cost based on future medical needs, pre-existing injuries, and co-morbid conditions, including the life expectancy of the claimant. Revisions are charged at the WC MSA and LMSA Revision rates.
Post Settlement Services
MSA SELF-ADMINISTRATION ASSISTANCE
Optum offers assistance for claimants who are willing and able to self-administer their MSA account. Our Self-Administration service includes unlimited phone and online support for all self-administration accounting needs, access to required forms, and repricing of medical bills for one year or more, depending on the level of assistance.
Beneficiary Determination and Authorization Services
SOCIAL SECURITY BENEFITS DETERMINATION
Upon receipt of a case assignment accompanied by a Social Security Release form, Optum will obtain Social Security Disability and Medicare status with the SSA. Optum will then contact the claim handler and provide the appropriate recommendation.
SECURING SIGNED RELEASES/AUTHORIZATION FORMS
If services require signed authorization, either by the claimant or the Registered Reporting Agent (RRE), then Optum will prepare and secure the necessary documentation from the appropriate party at the request of the adjuster.
Conditional Payment Services
Medicare, Medicare Advantage Plans, Part D Plans, Medicaid
CONDITIONAL PAYMENT VERIFICATION SERVICE
If Conditional Payment verification is requested, upon receipt of authorized forms, Optum will correspond with the Benefit Coordination and Recovery Contractor (BCRC) to determine if Conditional Payments exist. Written verification of Conditional Payment is obtained and provided to the adjuster.
CONDITIONAL PAYMENT DISPUTE FILING
After the analysis of the Conditional Payment demand is complete and it is determined that there are unrelated items included in the amount, Optum will obtain supporting documents, draft and file an agreement disputing the unrelated changes in order to reduce the total Conditional Payments amount.
CONDITIONAL PAYMENT APPEAL SERVICES TIER 2
Appeals at the Administrative Law Judge, review by the Medicare Appeals Council, and United States federal court action level are handled solely by our dedicated MSP Legal team.
DEPARTMENT OF TREASUREY OFFSET RESOLUTION
Upon the completion of a successful appeal, funds that have been taken as an offset by the Department of Treasury may be repaid. Optum will contract the Department of Treasury and provide the appropriate documentation to secure the repayment of the principle and interest taken as an offset.
CONDITIONAL PAYMENT ANALYSIS SERVICE
If Conditional Payments exist, our analyst will review the payment summary provided by Medicare and will perform a comparative analysis of the data reported to CMS via Section 111 Mandatory Insurer Reporting (MIR). Optum will then notify the adjuster in writing of any disputable charges and provide recommendations for payment and/or reduction of the Conditional Payments amount.
CONDITIONAL PAYMENT APPEAL SERVICES TIER 1
Medicare allows for the opportunity to initiate the formal appeal process by requesting a redetermination and reconsideration. Our dedicated Conditional Payments team will review the previous argument and response by Medicare and craft higher levels appeals to support the case through reconsideration.
DEPARTMENT OF TREASURY SEARCH
When provided with the appropriate authorization forms, Optum will engage with the Department of Treasury to request a list of claims currently in collections and heading to possible offset for each requested Tax ID.
CMS CONDITIONAL PAYMENT REFUND CHECK SERVICES
When refunds are owed from the Treasury or Medicare, Optum will act as the point of contact for management, providing tracking and delivery of checks to a designated client contact person and address.
Conditional Payment Program Management Services
AUTOMATED NOTIFICATION/VERIFICATION SERVICE
Optum will monitor claims that return a positive hit for Medicare Beneficiary status and review the case for current Conditional Payment actives for the associated date of injury. If no Conditional Payment activity found, Optum will establish the file with the BCRC and provide notification to the claim handler of the establishment of the case and any associated notices that are received as a result.
CONDITIONAL PAYMENT LETTER FORWARDING
If provided authorization, Optum will manage all incoming Conditional Payment correspondence on behalf of the RRE. Optum will receive, scan, log and forward the notice to the appropriate party for handling.
AUTOMATED NOTIFICATION/VERIFICATION RECHECK SERVICE
After Optum has established the claim with the BCRC, the claim will be monitored based on an agreed upon schedule to ensure Conditional Payment demands are identified and responded to in a timely fashion.
CONDITIONAL PAYMENT MANAGEMENT AND MONITORING
In conjunction with the Conditional Payment Letter Forwarding process, Optum will also monitor Conditional Payment due dates, send follow-up notices and provide reports tracking the status of the demand.
TIN SMART SWEEP
Designed to help mitigate risk with CMS correspondence going to old addresses, Optum will update the RRE address, recovery agent address or both, on a previously reported claim.
Note: Non-complex sweeps encompass a single RRE ID and data from a single third-party reporting agent (TPRA) or TPA. Total records not to exceed one hundred TIN records. This service is dependent on cooperation from prior TPRA or TPA to accurately provide historical data related to prior CMS reporting submissions.
PART D DETECTOR (CANDIDATE LIST)
Upon receipt of detailed pharmacy transactions, a list of claims will be provided to the client that meets certain criteria, which may indicate potential prescription drug concerns or high prescription drug usage. If the client is a Pharmacy Benefit Management (PBM) client of Optum, a list of claims will be provided to the client that meets these criteria. This will alert adjusters to potential high exposure prescription drug issues that may require intervention.
CLINICAL COST CONTAINMENT REVIEW (CCCR)
A comprehensive review of pharmacy history and medical treatments which identifies clinical recommendations for potential cost savings in multiple areas of a claim. Clinical pharmacists perform a Medication Analysis while clinical nurses, trained in CMS guidelines, review treatment records evaluating all aspects of medical treatment including Durable Medical Equipment (DME), surgeries, home health care, diagnostics and supplies. Mitigation opportunities are identified using evidence-based guidelines and an action plan to address therapeutic concerns and cost containment is provided.
NURSE PROGRESS MONITORING-TELEPHONIC CASE MANAGEMENT
Targeted follow-up with the treating physician is recommended for all Medication Analysis and CCCR referrals following peer outreach. Outcomes are reviewed with the claims professional by a clinical nurse. The primary treating physician’s office is contacted before and after the claimant’s scheduled appointments, encouraging compliance. Therapeutic changes are validated by monthly file reviews with case re-evaluation at the end of six months.
Optum’s Medication Analysis provides a comprehensive assessment of the injured party’s pharmacy records and current medication regimen by an Optum clinical pharmacist, trained in CMS guidelines.
After this thorough review, a summary report is created detailing specific clinical recommendations to address therapeutic concerns regarding the claimant’s medication therapy as well as cost containment action plan.
Outreach is recommended on all Medication Analysis and CCCR assignments when mitigation opportunities are identified. Specialty-matched peer physician(s) collaboratively engage the treating physician to discuss all aspects of the case and determine alternative treatment strategies that are consistent with standards of care and facilitate implementation of recommended changes. The peer physician will attempt to obtain verbal or written clarification of the agreed upon current and/or future treatment recommendations. Outreach is made based on the state’s ex parte rules.
FIELD CASE MANAGEMENT (FCM)
Optum will assign a FCM to the case based on client approved triggers or authorization from the claim handler. FCM services can be used in conjunction with Peer Outreach and Nurse Progress Monitoring services to provide the opportunity for an in person visit to facilitate treating physician cooperation with this process, when needed. Outreach is made based on the state’s ex parte rules.
MSA CLINICAL OUTREACH (RN/PHARMACIST or PHYSICIAN*)
Upon identification of items in a MSA lacking proper clarity, including outdated recommendations or drug therapies where the prescribed reason for usage is unclear, a clinical nurse or physician will then outreach to the treating physician(s) to discuss the concern(s) and obtain verbal and written clarification of the current and/or future treatment recommendations. Following written confirmation of treatment, the MSA allocation can be adjusted. Optum recommends the use of the physician outreach for claims with high allocations following initiation of settlement process, where there are complex therapy concerns or the treating physician(s) prefer to discuss the case with a peer-level physician.
Note: *Includes up to two hours of Peer-to-Peer review/interaction. Anything beyond two hours is an additional charge per 15-minute increment.
Optum will provide a consult with one of our staff attorneys for assistance with settlement language, settlement strategy discussion and review of current law.
Assistance with triaging a case for possible mitigation, review of appropriateness and necessity on the claim.
PROFESSIONAL MSP/MIR SERVICES
Optum has a full staff of experts that
are available to discuss MSP/MIR
As an industry-leader in innovative and comprehensive solutions for MSP compliance, Optum delivers a customizable platform that provides tools and advanced reporting capabilitie for MIR through MedicareConnect.
QUERY DATA VALIDATION
By working with strategic partners Optum leverages public databases to validate the five key data elements to be able to accurately query, identify or determine Medicare eligibility status, and report a claim for Section 111.
TAXPAYER IDENTIFICATION NUMBER (TIN) SMART SWEEP
We use database script to update recovery agent fields prior to each submission to CMS to ensure any recovery related mail is directed to the proper location for handling in addition to the RRE address.