Business insurance

Optum Rx will pay $5.8 million for failing to follow underwriting procedures

The Massachusetts Attorney General’s Office announced that the pharmacy’s benefits manager, Optum Rx, agreed to pay $5.8 million to settle a claim that it failed to follow drug pricing procedures. on workers compensation order.

However, Optum did not admit to any of the wrongdoings alleged in the settlement filed Wednesday.

“The settlement, filed in Suffolk Superior Court, resolves allegations that Optum Rx, in certain circumstances, failed to apply various regulatory benchmarks – such as the federal upper limit for Medicare and the Massachusetts maximum allowable cost – to its rating determinations for certain workers’ compensation prescription drug benefits,” the attorney general’s office said. “These failures, according to the settlement, would have occurred on various injured worker prescriptions filled in Springfield, New Bedford, Boston and Worcester at Walgreens, CVS and RiteAid sites.”

Optum Rx pays pharmacies that fill prescriptions for injured workers and bills insurers and self-insured employers for medication through the workers’ compensation system. The attorney general’s office argued that failure to follow regulatory processes intended to prevent extra billing “allowed excessive drug costs to enter the workers’ compensation system.”

In addition to the $5.8 million payment, the terms of the settlement also require Optum Rx to ensure that billings and payments comply with state laws and regulations going forward. To facilitate compliance, Optum Rx must develop a pricing protocol that is further described in a separate agreement with the state Attorney General, according to the settlement.

The company has also agreed to cooperate with the Attorney General’s Office in future compliance monitoring efforts.

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