Catalog of Services Medicare Compliance Services for Workers Compensation and Liability Claims

Transcription

1 Catalog of Services Medicare Compliance Services for Workers Compensation and Liability Claims

2 With Optum, you can expect industry-leading settlement services and insight at competitive prices and, more importantly, no surprises. Our Settlement Solutions team understands the distinctions between liability and workers compensation settlements and delivers a comprehensive portfolio of services tailored to fit the complexities of both. 2

3 The Medicare Secondary Payer Act creates added complexity to the claim settlement and disposition process for claim handlers, third party administrators, self-insured entities, insurance carriers, attorneys and the claimant. Our Solution Our Settlement Solutions simplifies the process for all stakeholders and delivers products and services making the settlement process easier for all. Leveraging the expertise of pharmacists, nurses, life care planners, attorneys, and experienced claim professionals, Optum recognizes no two claims are alike. Our collaboration with our clients assures we know the facts, we understand the objectives of the case, and you know what to expect. Beginning with our industry leading MMSEA Section 111 Reporting platform, MedicareConnect, our clients know when their data is sent to the Centers for Medicare & Medicaid Services (CMS) it contains only those claims required to be reported and the claim records will be accepted. Our validations don t stop with submission. We work with every customer to audit the data in search of inconsistencies and erroneous codes and provide tools to manage the information at a program level. Advantage of early detection Early recognition and intervention on clinical and cost issues lead to better outcomes. We provide various tools and reports such as our Part D Detector to identify claims for intervention much earlier in the claim life cycle than any other Medicare Secondary Payer (MSP) Compliance partner. Interventions such as our Medication Analysis and MSA Clinical Outreach Services help to mitigate costs, improve clinical outcomes and pave the way to a smooth settlement process. An accurate Medicare Set-Aside and the resolution of conditional payments or other liens requires expertise and cross-functional resources. And once the claim has settled, we offer tools and services to assist with the administration of the settlement funds. 3

4 Workers Compensation and Liability Settlement Services Medicare Set-Aside (MSA)... 5 Medicare Set-Aside (MSA)... 5 Second Opinion MSA...5 MSA Clinical Outreach... 5 CMS Approval of MSA...5 CMS Amended Review of MSA...5 Rush Services...6 Social Security Verification... 6 Self-Administration Assistance... 6 Conditional Payment/Lien Services Overview... 6 Conditional Payment Verification Service... 6 Conditional Payment Analysis Service... 6 Conditional Payment Dispute Filing Service... 6 Conditional Payment Appeals Services... 7 Department of Treasury Off Set Resolution... 7 Cost Containment Tools Cost Containment Tools... 8 Medication Analysis... 8 Clinical Cost Containment Review (CCCR)... 8 Drive Cost-Saving Treatment Changes... 8 Peer-to-Peer Outreach... 8 Nurse Progress Monitoring... 8 Part D Detector...9 Liability Allocations Liability Allocations... 9 Liability Medicare Set-Aside Allocation (LMSA)... 9 Liability Future Medical Allocation (LFMA)... 9 Limited Liability Future Medical Allocation Second Opinion Allocation CMS Approval of Allocation (Applicable to LMSA only) Settlement Tools Future Medical Cost Projection (FMCP) Medical Reserve Forecast Section 111 Reporting MedicareConnect Query data validation

5 Workers Compensation and Liability Settlement Services Medicare Set-Aside Services Overview Medicare Set-Aside (MSA)* Our MSA allocations include customer-requested special handling, rated-age determination and the overall lowest defensible MSA in the industry. Our all-inclusive solution includes a non-medicare grid and a comprehensive medical write-up. Second Opinion MSA A quality MSA ensures your interests are protected while containing costs. Our experts can re-evaluate an MSA allocation completed by another provider to ensure accuracy and that the lowest defensible allocation has been obtained. MSA Clinical Outreach An Optum MSA specialist reviews an MSA allocation to identify items lacking proper clarity, including outdated recommendations or drug therapies where the prescribed reason for usage is unclear. An action plan to address specific items requiring clarification with the treating physician(s) is created and provided to the client. A peer physician or clinical registered nurse (RN) then enters into a collegial discussion with the treating physician(s) to better understand the clinical situation and discuss the concern(s) identified. The physician or nurse will attempt to obtain verbal and written clarification of the agreed upon current and/or future treatment recommendations. Following written confirmation of treatment, the MSA allocation is adjusted. Physician outreach is recommended for claims with high allocations following initiation of the settlement process, where there are complex therapy concerns or the treating physician(s) prefer to discuss the case with a peer-level physician. CMS Approval of MSA Once we have completed the MSA allocation and received a request from the client for CMS approval, the necessary documentation is prepared and submitted to CMS. This service includes one resubmission and negotiation, if necessary. CMS Amended Review of MSA Our dedicated CMS submission team will review the previously approved MSA to determine if the claim can be submitted for an Amended Review and for cases meeting the requirements we will complete the revised allocation and provide the necessary supporting documentation for review. *Upon request and receipt of additional material, a MSA revision can also be completed to update the MSA allocation. Revision fees apply. 5

6 Rush Services MSA Allocations, CMS Submissions, Revisions, and Liability Future Medical Allocations are available as a two or five-business day rush service. Social Security Verification Upon receipt of a case assignment accompanied by a properly executed Social Security Release form, we will determine Social Security Disability and Medicare status. Based on the result, the need for an allocation is determined. We then notify the client of the status. Self-Administration Assistance We offer assistance for claimants who are willing and able to self-administer their MSA account, but are seeking coaching and education on how to properly manage this process. Our Self-Administration Assistance service includes unlimited phone and online support for all self-administration accounting needs, access to required forms and re-pricing of medical bills and can be provided for one year or more, depending on the level of assistance required. Conditional Payment/Lien Services Overview Our dedicated team of Conditional Payment Specialist resolve conditional payments and liens from Medicare, Department of Treasury, Medicare Advantage Plans and Medicaid. Resolving conditional payments takes a multidisciplinary team able to apply clinical and legal expertise in crafting arguments to dispute charges. Conditional Payment Verification Service If conditional payment verification is requested, upon receipt of authorized forms we correspond with the appropriate agency to determine if conditional payments exist. Written verification of conditional payment is obtained and provided to the client. Conditional Payment Analysis Service If conditional payments exist, our Conditional Payment Specialist reviews the payment summary provided, and performs a detailed analysis of all file materials. We then notify the client in writing of any disputable charges and provide recommendations for resolution and reduction of the conditional payment amount. Conditional Payment Dispute Filing Service If the client then requests an appeal/dispute, we will work in conjunction with the client and the lien holder in order to reduce the total conditional payments amount. 6

7 Conditional Payment Appeals Services Medicare allows for the opportunity to initiate the formal appeal process by requesting redetermination. Our dedicated conditional payment team will review the previous argument and response by Medicare and craft higher levels appeals to support the case through reconsideration, a hearing by an Administrative Law Judge, review by the Medicare Appeals Council, and United States federal court action. Department of Treasury Off Set 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. 7

8 Cost Containment Tools Medication Analysis Our Medication Analysis provides a comprehensive assessment of the injured party s pharmacy records by an Optum Clinical Pharmacist, trained in CMS guidelines. After this thorough review, a summary report is created detailing specific clinical recommendations regarding the injured party s medication therapy as well as a cost containment action plan. Clinical Cost Containment Review (CCCR) CCCR is a comprehensive review of pharmacy and medical treatment which identifies potential cost savings in multiple areas of a claim. Clinical pharmacists review pharmacy and medical treatments for therapeutic appropriateness of treatment, duration and future medical needs. 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. Utilization control opportunities for medical and medication therapies are identified using evidence-based guidelines and an action plan to address unnecessarily high-cost items is provided. Drive Cost-Saving Treatment Changes Peer-to-Peer Outreach Upon request, after a CCCR or Medication Analysis, a specialty-matched peer physician enters into a collegial discussion with the treating physician(s) involved in the case to better understand the clinical situation and if warranted, educate the prescriber(s) regarding appropriate therapeutic options/alternative treatment strategies, so that recommended changes in the treatment plan may be implemented to achieve cost savings. Nurse Progress Monitoring We offer Nurse Progress Monitoring as an adjunct to the Peer-to-Peer Outreach service associated with a CCCR or Medication Analysis. This program is performed by a registered nurse experienced in workers compensation claims. Upon request, following Peer-to-Peer Outreach, a registered nurse will provide detailed telephonic communication over a six-month period with the treating provider. This helps to ensure the agreed upon recommendations for change are implemented. 8

9 Part D Detector Our proprietary Part D Detector evaluates pharmacy data and proactively identifies cases that may benefit from an intervention program to decrease pharmacy costs. Claims are scored based on certain criteria which may indicate potential prescription drug concerns or high prescription drug usage, then ranked in order of highest potential for treatment change/cost savings. A list of these claims is then provided to the client at pre-determined intervals to alert them to potential high exposure prescription drug issues which may require clinical intervention. Liability Allocations Our allocations include customer-requested special handling, rated-age determination and the overall lowest defensible allocation in the industry. Liability Medicare Set-Aside Allocation (LMSA) This conservative solution is specifically designed to emulate the workers compensation guidelines from the Centers for Medicare and Medicaid Services (CMS) and provide documentation of compliance with Medicare Secondary Payer (MSP) Act for liability settlements. The LMSA is a detailed report which includes a comprehensive medical write-up and incorporates all liability-specific aspects of the claim. With our expertise in the areas of pharmacy, medical, legal and claims we provide the lowest defensible LMSA. Liability Future Medical Allocation (LFMA) This aggressive solution utilizes both a clinical and legal approach to produce a reasonable and accurate future medical allocation that is based on the facts of each individual case to assist in complying with the MSP Act. Our cross-disciplinary expertise in pharmacy, medical, legal and claims allows us to effectively combine all aspects of cost containment. We utilize medical and pharmaceutical standards of care, cost-effective pricing, application of the distinct legal facts of each case, as well as other evidence-based mitigating tools. This aggressive and cost-minded approach provides for the lowest and most accurate allocation while appropriately protecting Medicare s interest. 9

10 Limited Liability Future Medical Allocation This cost-effective report is tailored for situations in liability claims where the monetary amount of the settlement does not justify the expense of a comprehensive LFMA. We understand the need for flexibility as not all settlements require the same extensive documentation. With our cross-discipline expertise in pharmacy, medical and claims, we can provide you with an allocation to close your smaller claims for a lesser fee while still ensuring compliance with the MSP Act. The Limited LFMA is available when the allocation is $15,000 or less and the claimant requires only limited future medical care. Allocation Revisions Upon request and receipt of additional material, a revision can be completed to update the liability allocation. Second Opinion Allocation A quality liability allocation ensures your interests are protected while containing your costs. Our experts can re-evaluate a liability allocation completed by another provider to ensure accuracy and that the lowest defensible allocation has been provided. CMS Approval of Allocation (Applicable to LMSA only) Once we have completed the allocation and received a request from the client for CMS approval, the necessary documentation is prepared and submitted to CMS. This service includes resubmission and negotiation, if necessary. Settlement Tools Future Medical Cost Projection (FMCP) An unbiased independent medical summary, the FMCP takes into consideration all future medical treatment for the compensable claim under review. The future medical needs, pre-existing injuries, and co-morbid conditions, including the life expectancy of the injured party are all taken into consideration. An MSA will be included at no charge if requested at the time of referral. Medical Reserve Forecast Our Medical Reserve Forecast provides future medical needs on claim files at any time along the treatment continuum. Our exclusive Medical Reserve Forecast will assist you in identifying the probable ultimate medical cost of a claim, which prevents stair-stepping and allows for more exact claim reserving. The Medical Reserve Forecast can be tailored to your claims system and reserving worksheet for easy import capabilities. 10

11 Section 111 Reporting MedicareConnect As an industry-leader in innovative and comprehensive solutions for Medicare Secondary Payer (MSP) compliance, Optum delivers a customizable platform for Mandatory Insurer Reporting (MIR) through MedicareConnect. This system provides tools and advanced reporting capabilities that allow payers to achieve compliance with MIR requirements, streamline workflows and minimize risk. Query data validation Working with strategic partners Optum leverages public databases to validate the five key data elements to be able to accurate query and report a claim for Section 111. Contact us at or OptumMSA@optum.com to make a referral or learn more about our MSP services or any of our other workers compensation and auto services. 11

12 About Optum for Workers Compensation and Auto No-Fault Optum Workers Comp Solutions collaborates with clients to lower costs while improving health outcomes for the claimants we serve. Our comprehensive pharmacy and ancillary care services combine data, analytics, and extensive clinical expertise with innovative technology to ensure injured workers receive safe, efficacious and cost-effective care throughout the lifecycle of a claim. For more information, us at expectmore@optum.com. Optum and its respective marks are trademarks of Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer Optum, Inc. All Rights Reserved. STS _ 05/18 12