Medicare Compliance & Reimbursement

If you're wrangling with your carrier to accept your electronic Medicare secondary payer claims, you're not alone.

Approximately two years ago, several Medicare carriers told practices that they would no longer process Medicare secondary claims unless practices submitted the claims electronically.

Snag: Most billing software systems can't handle Medicare secondary claims data, however, making the process cumbersome.

Unfortunately, most payers haven't streamlined their systems too much since then, and practices are still struggling with how they can collect when Medicare is the secondary payer.

"We are not having luck filing these claims," says Vicki Williamson of Carrollton Ear, Nose and Throat in Carrollton, GA. "I was told by Medicare if my practice management system and clearinghouse did not have the capability to send these electronically, then the only way to submit them is through a program you download from their Web site."

And although her payer only accepts Medicare secondary claims electronically, other carriers accept only paper claims from her. "I just think we need some consistency with the requirements," she says.

One solution: "Our electronic clearinghouse was able to help us with this issue," says Ben Willis of Accurate Medical Billing. "We had to add something in the user note in our system that allowed the clearinghouse to pick it up."

Unfortunately, Willis says, "I also have to manually add the primary insurance's allowable, date of payment, how much they paid, how much they put to the patient's responsibility and for what reason, and how much the primary adjusted off and for what reason," Willis says.

He then enters that information into software that his clearinghouse gave him. "It takes a little bit of time, but that seems to be the solution for us currently," Willis says.

When is Medicare secondary? According to Chapter 10 of Medicare's Internet Only Manual (IOM), "When a primary plan's payment for Medicare covered services is less than the provider's, physician's, or other supplier's charges for those services and less than the gross amount payable by Medicare, and the provider, physician, or other supplier does not accept and is not obligated to accept the primary plan's payment as full payment, then contractors can process Medicare secondary payment as appropriate."

Learn more: To read the IOM's section on Medicare secondary payments, visit http://www.cms.hhs.gov/manuals/downloads/msp105c01.pdf.