Practice Management Alert

 When dealing with crossover claims, practices often confuse Medicare secondary insurers with Medigap insurers, says Pamela Sharkey, CPC, CMM, administrator of Medibilling, a company that provides centralized billing for individual doctors and physician groups in Paramus, N.J.
  
Medigap is a private insurance designed to pay for the patient's cost-sharing items under Medicare and to fill in the gaps for items Medicare does not cover. This supplemental insurance is standardized into 10 types of policies and is regulated by the federal and state governments. Medigap claims transfer from Medicare to the insurance companies that provide those policies. To coordinate the benefits of the two insurance plans, namely Medicare and the secondary insurance, Medicare carriers offer "complementary crossover," an arrangement carriers have with insurers to forward Medicare claims to the secondary plan.
  
When Medigap claims transfer, only the claim information from Medicare participating providers is transferred. When secondary claims crossover, Medicare claims' data from both participating and nonparticipating providers are transferred to the secondary insurer. The Medigap transfer and the secondary crossover have different data requirements. The Medigap transfer is controlled by information on the claim form and depends on the Medicare participation status of the provider. Items 9 A-D on the HCFA 1500 claim form must be completed for a Medigap claim transfer.
  
Practices often make the mistake of filling in items 9 A-D on the HCFA 1500 claim form for a secondary insurer, which confuses the crossover process. Those line items are for Medigap insurance only, not secondaries. Carriers vary on their data requirements, so check with your carrier about what information they want and don't want on the claim form when secondary insurance is involved.
Secondary Controls Crossover Data   
Each secondary carrier can specify criteria related to the claims it wants to cross over, which excludes some types of claims from the crossover process. Examples of the types of claims secondary insurers often exclude from crossover are those that are:

   reimbursed at 100 percent
   for services the secondary does not cover
   for services provided outside of the plan's effective date and ending date
   denied as duplicates
   denied for missing information
   for services applied to the deductible.

Causes of Crossover Problems
When Medicare crossover does not work, it may be caused by common problems:

   The Medicare patient's secondary insurer does not have a contractual arrangement for crossover with the Medicare carrier.

   The Medicare patient's secondary insurer is on the carrier's list of participating crossover companies, but crossover is not set up for the patient's plan or policy.

   Crossover is in place for the Medicare patient, but an error occurs when the secondary's eligibility file is run against the Medicare carrier's paid-claims file. A secondary insurer may omit a Medicare beneficiary from its crossover eligibility file, [...]