ED Coding and Reimbursement Alert

It's the practice's responsibility to know which payer to bill first, Part B rep says.

Picture this: A patient presents to your front desk with a valid Medicare card. You report the claim for her services, only to find that the service is denied because Medicare should not have been the primary payer. If this has happened to your staff before, then perhaps it's time to review your Medicare Secondary Payer (MSP) prowess.

What it is: The term "Medicare Secondary Payer" refers to situations where another payer has primary payment responsibility for care provided to a Medicare beneficiary, said CGS Medicare's Vanessa Williams, who spoke during the Part B payer's March 21 webinar, "Medicare Secondary Payer: The Basics." Medicare Secondary Payer (MSP) is different from a "Medicare supplement insured," patient (also known as Medigap), in which Medicare is always primary and has a private health insurance policy as his or her secondary insurer. "Medigap is totally different than Medicare Secondary Payer," Williams said.

Several factors determine whether Medicare is primary or secondary, such as the patient's age or employment status, as well as diagnoses such as end stage renal disease.

Example: Williams offered the following case scenario when Medicare would be the primary payer. "There's an individual 65 or older covered by a group health plan through a current employer or spouse's employment. The individual is entitled to Medicare and the employer has less than 20 employees. In that case, Medicare would pay first and the group health plan would pay second."

If, however, the same scenario occurs but the employer has more than 20 employees, the group health plan would be the primary payer and Medicare would be secondary, she said. Because of subtle differences like these, it's important to create a tool for reference so you always know which payment plan is primary, she said.

Your responsibility under MSP: The reality is that you may not know when a patient's employer has 20 employees or fewer, but it's your responsibility to ask patients for all of the most accurate data you can get to allow you to have all of the information you need to make the determination. "You also want to follow the rules to obtain MSP information," Williams said. "This is based on group health insurance through their employer. If you know they're working still, ask them questions and get the information from them. If it's a non-group health coverage from an injury or illness, this also should be identified by you communicating with your patients," she added.

Fortunately, CMS offers a questionnaire that leads you through the right questions to ask to determine who the primary payer is. "A lot of times, Medicare Part B providers do not use the questionnaire form. It's not mandated," she said. "But it is something that can assist in getting to know whether Medicare is the primary or the secondary payer." It is required by Part A providers, she added.

Reference: You can find the questionnaire in Chapter 3 of the Medicare Secondary Payer Manual, available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c03.pdf.