F R O M   T H E   F I E L D

Staying in Compliance When Medicare Is the Secondary Payer
By Delly Parham, AS, CPC-A

Billing Medicare when another payer is primary can be confusing, causing providers to improperly bill patients or write off the balance. Here are some steps to help you stay in compliance and receive payment:

• You cannot bill the patient for any amount unless the secondary claim has been filed with Medicare, and Medicare determines the amount owed by the patient.
• Don't submit a claim to Medicare if the patient has met his or her deductible and the amount paid by the primary payer is equal to or more than the amount the patient owes.
• If the patient's deductible is not yet met, submit the claim to Medicare anyhow. While Medicare won't pay, it will apply the patient's payment to his or her deductible.

Even if you are satisfied that the amount paid by the primary payer is more than the Medicare allowed amount, and you will not bill the patient, you may still wish to file the claim with the Medicare secondary payer. If the primary payer later determines that it is not the primary payer and requests a refund, the claim will be on file with Medicare and will not be denied for timely filing.

It may cost less to forego filing the claims with Medicare than the amount that may be written off due to timely filing. A large practice with large outstanding amounts could benefit from filing the claim with the Medicare secondary payer, while this may not be cost effective for a small practice or for small amounts outstanding.

There may be specific guidelines for insurances such as automobile or workers' compensation in states with no-fault. There may be some in Veterans Affairs or other government insurances. Comply with the requirements of these payers prior to filing with Medicare as Secondary Payer.

G O O D   T I P S

Good Management: Hands-on While Being Hands-off

No employee enjoys someone looking over her shoulder while she works. Yet, no practice manager likes to be surprised by errors and low productivity. How can you achieve a balance?

Industry leaders recommend being hands-on while being hands-off by entrusting your employees to do well-defined roles, stepping back, and holding them accountable. Micromanaging can be counter-productive. Different employees have different work styles. All employees perform best when they perceive their skills are valued and their decisions are trusted.

Know not only each employee's role, but also the employee. Provide regular feedback so employees know their work is being monitored and they will be held accountable. Experienced managers know that trusted employees are motivated to do their best, leaving the practice manager free to concentrate on other things.

F E A T U R E D   S T O R Y

66 Days to 5010 Compliance. Ready?

If you are waiting for the Jan. 1, 2012 implementation date for 5010 standard compliance to be pushed back, you may be disappointed. At that time, any billing transactions using the 4010 standard will be rejected as non-compliant.

Providers can test transactions with Medicare administrative contractors (MACs) and clearinghouses through the end of the year. And they'll want to. Improvements made since testing began include clearer instructions, reduced ambiguity among common data elements in different transactions, and elimination of unnecessary data elements.

The advantage of 5010 is more specificity to support ICD-10-CM, but it requires more data, often in a different format. For example, providers must provide street addresses rather than PO boxes, and anesthesia services will be reported in minutes rather than units.

Make sure your software vendors upgrade your systems to 5010 standards. Communicate with your MACs and clearing houses to ensure they will be ready when you are. Train your billing and coding staff, including those at the front desk, so that everyone is ready.

Find out more information about preparing from the Centers for Medicare & Medicaid Services or AAPC.

FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies, or just anecdotes please submit them to us for future editions.

In This Issue
Compliance & Medicare
Good Management
5010 Compliance

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