Medicare as Secondary Payer

Cant Tune in live?

Click here to
buy the cd of this conference.

When your claim stops first at another payer on the way to your Medicare carrier, the rules change a little bit. You’re stuck with competing between the private payer’s claims rules and Medicare’s, a balancing act that often results in write-offs that can add up. Most of these write-offs are avoidable – if you maneuver the rules correctly

Reimbursement pro Kim Huey will detail:

The most common errors that trip up claims that go to Medicare as secondary with her best strategies to avoid them.
How to fill out claims that can thread the needle between private payer and Medicare payment – so you don’t forgo payment all together.
How to get key fields on the CMS-1500 (or electronic equivalent) filled out correctly for both payers.

The limiting charge also applies to primary insurers when Medicare is secondary, not just when Medicare is primary flag the bill-Medicare-first cases and save your office time and trouble When you file a claim for secondary benefits, the single most important thing to remember is this: Include a copy of the insurance company’s explanation of benefits (EOB). Your carrier will match up the items and amounts on that EOB with the items and amounts on your claim. Also:

Check to make sure the basic patient information on your claim matches the information on the EOB. Review dates of service and spellings of names. If there’s a difference, correct or explain it.
Make sure you submit an itemized claim and make sure the amounts on your claim match up with the amounts listed by the employee insurance plan.

Avoid the run-around from primary payers. A insurance carrier cannot avoid primary payer status by arguing its contract requires Medicare to pay first. If an employer’s insurance plan refuses to pay on those grounds, refer the carrier’s representative to CMS 100-5, 1 §10, which states in part:
“SSA §1862(b)(2)(A)

If you agree or are obligated to accept as full payment a patient’s primary insurance fee schedule amount – and it’s less than the Medicare allowable for that service and the primary insurer pays – can you bill Medicare for the difference?

No, you cannot. A contracted agreement to accept a primary insurance payment as payment in full reduces the patient’s balance to zero if the primary insurance makes its full payment. You should still submit the zero balance claim to Medicare, however, so the patient’s Medicare deductible can be credited as necessary. Attach the primary insurance claim with the amount of payment received to the Medicare secondary claim so Medicare can determine the amount that should be credited to the patient’s deductible.

If Medicare pays a claim for which your practice should not have received payment, such as paying additional money on a zero balance claim, you are responsible for returning that money to the carrier.

If you do not have a contract with the primary payer to accept its payment as full payment for a service, then you may bill Medicare for the payment difference if Medicare pays more for the same service.

You billed the patient’s primary insurance and it paid in full. But the patient has Medicare as secondary insurance. Should you send Medicare a claim, even if there is no balance for the program to pay?

Yes, you should. If you don’t, you are potentially cheating the patient out of credits to the $100 Part B annual deductible. Failure to file a secondary payer claim to Medicare in this instance would be a violation of Medicare billing rules. Even if you know the patient’s Part B deductible has been met for the year, you must send all zero balance claims to Medicare.

Payments that ordinarily would be credited toward the Medicare deductible are still credited to the deductible when paid by a third-party payer.

Remember the MSP and cut a common source of denials

Take care not to commit this perennial claims error: Failing to fill in Item 11 of the CMS-1500 claim form (or its electronic equivalent). The mistake routinely ranks among the top reasons for denials measured by carriers nationwide.
Item 11 of the CMS-1500 asks for the “insured’s policy group or FECA number” and tells carriers you have made a “good faith effort” to determine whether Medicare is the primary or secondary payer.

The field cannot be left blank. If you leave it blank, your carrier will reject the claim and ask you to resubmit with the field completed. Look for denial code MA83, which means failure to “indicate whether Medicare is primary or secondary payer.”

Solution: If no insurer other than Medicare is primary, list the word “NONE” in Item 11. If an insurer other than Medicare is primary, list that insurer’s name.

Tip: When there’s an insurer primary to Medicare, you have to do more than list the insurer’s name in Item 11. In addition to submitting a copy of the primary payer’s Explanation of Benefits (EOB) for the claim, you must also supply:

Item 4: Insured’s name.
Item 6: Patient’s relationship to insured.
Item 7: Insured’s address.
Item 11c: Insurance plan name/program name.

CEUs:

AAPC 1 CEU
This program has prior approval of the American Academy of Professional Coders (AAPC) for 1.0 Continuing Education Units. Granting of this approval in no way constitutes endorsement by the Academy of the program, content or the program sponsor.

BMSC 1 CEU (ASC and SCP)
See BMSC’s web site for details – www.medicalspecialtycoding.com

Sponsors:

Part B News, the nation’s leading independent newsletter and Total Information Service, helps physician practices and hospitals bill for Medicare services, comply with complex Medicare payment rules, produce cleaner claims and reduce denials.

DecisionHealth®, publisher of Part B News, ICD-9/CPT Coding Pro and Coding Answer Book, serves the business and regulatory needs of health care practitioners, providers and their administrative staff nationwide by offering more than 50 independent newsletters, magazines, books, web sites and loose-leaf services that help readers make the best business decisions. www.decisionhealth.com.

To find out about upcoming conferences and for a complete listing of audio CDs, please visit www.decisionhealth.com.

One registration fee lets your entire staff listen in! Save money - no travel expenses!