Medicare Compliance & Reimbursement

Start with all insurance cards, not just Medicare.

If your practice’s internal audits show errors from billing Medicare Secondary Payer (MSP) claims as primary, follow these important tips for filing MSP claims, outlined in MLN Matters article SE1217.

1. Verify all of the patient’s insurers. Get copies of all the patient’s insurance cards when they come to your practice. Sometimes a patient might present his Medicare identification card, but not the cards for additional payers. This could cause unnecessary denials if you’re inappropriately billing Medicare as primary. The opposite situation can also throw a kink in your coding. If the patient is of Medicare age and the Medicare information isn’t provided, the patient may have MSP, but there’s no way to know that for sure unless you specifically ask whether the patient has secondary coverage.

2. Bill the primary payer first. You can’t submit claims to the patient’s primary payer and the MSP at the same time. Instead, you must bill the primary payer and then wait for the remittance advice from that insurer before you submit to the MSP. “After receiving the primary payer remittance advice, then bill Medicare as the secondary payer, if appropriate,” CMS says in the article. “If a patient is seen for multiple services, each service should be billed to the appropriate primary payer.”

3. Single out accident claims. If your patient has an open MSP liability, no-fault, or workers’ compensation record, you should bill those payers first, but do not deny treatment, CMS advises.

You’ll submit to the accident payer first (for instance, the workers’ comp insurer), and then to MSP with the first payer’s remittance information. If the accident payer did not pay you for the accident-related services, “Medicare will need this information to process your claim accordingly,” the MLN Matters article notes. “If you follow these procedures, you do not need to wait 120 days to submit your claim to Medicare for payment.”

Tip: Be alert to clues on the demographic information provided by the hospital. For example, if the procedure is resulting from an accident, there may be a liability carrier involved (automobile, worker’s compensation for working elderly, etc.).

4. Communicate directly with your MAC. If you believe your Medicare primary or secondary claim was denied inappropriately, contact your MAC immediately. “You may need to provide information to your Medicare contractor that demonstrates why the claim was denied inappropriately,” the MLN Matters article notes. For example, a diagnosis code may have been mistakenly applied to the patient’s worker’s compensation Medicare Secondary Payer record. “Indicate to the Medicare contractor that the service performed is not related to the accident or injury, and Medicare should adjust and pay the claim if it is a Medicare covered and payable service,” the article says.

5. Report MSP updates to the COBC. If you believe a patient’s Medicare Secondary Payer record has errors on it, contact the Coordination of Benefit Contractor (COBC) at 1-800-999-1118 to update the file. The COBC can’t fix your mistakenly-denied claims or find your missing payments, but it can get the patient’s records straightened out so that future claims are paid appropriately.

Resource: To read the complete MLN Matters article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1217.pdf.