Medicare Secondary Payer

Cahaba GBA’s
2014 Medicare Expo
August 6, 2014
Chattanooga, TN
Medicare Secondary Payer (MSP) - Basics
Presented by
Renea Cloud
Part B Provider Outreach and Education
As directed a copy of the presentation is available for viewing or
download on the Cahaba GBA website
Disclaimer
This resource is not a legal document. This presentation was
prepared as a tool to assist our providers. This presentation
was current at the time it was created. Although, every
reasonable effort has been made to assure accurate
information, responsibility for correct claims submission lies
with the provider of services. Reproduction of this material
for profit is prohibited.
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Agenda
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Medicare Secondary Payer Overview
Coverage Primary to Medicare
Claim Submission Requirements
Sample MSP Claim Payment Calculation
MSP Adjustments & Overpayments
MSP Tips
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Medicare Secondary Payer
Overview
3
Medicare Secondary Payer Overview
Medicare Secondary Payer Defined
• Medicare Secondary Payer or MSP refers to Medicare benefits
when Medicare is not the primary insurance
• Medicare requires all health care providers to know how to
determine when Medicare is the primary or secondary insurance
for their Medicare patients
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/msp105
c01.pdf
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Medicare Secondary Payer Overview
Medicare Secondary Payer Statute
• The Medicare Secondary Payer (MSP) statute, Section 1862 (b) 42
U.S.C. Section 1395y(b), provides that when Medicare payment
that a "primary plan" was obligated to make, the payment is only
conditional and Medicare is entitled to reimbursement
http://www.ssa.gov/OP_Home/ssact/title18/
1800.htm
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Medicare Secondary Payer Overview
Initial Enrollment Questionnaire (IEQ)
• Healthcare coverage questionnaire sent to beneficiaries prior to
Medicare entitlement
• 5 Types of IEQs:
– Working Aged
– End-Stage Renal Disease
– Disabled
– Disabled Widow/Widowers
– Disabled Adult with Childhood Disabilities
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Medicare Secondary Payer Overview
Common Working File (CWF)
• The Common Working File is Medicare’s application that
maintains information regarding coverage for Medicare
Beneficiaries
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Medicare Secondary Payer Overview
Benefits Coordination & Recovery Center (BCRC)
• Established to collect, manage, and maintain information on the
Common Working File (CWF) regarding other health insurance or
coverage for Medicare beneficiaries
• Identifies and recovers Medicare payments that should have
been paid by another entity as the primary payer either under a
Group Health Plan, or as a part of a Non-Group Health Plan claim
which includes, but not limited to Liability Insurance, No-Fault
Insurance, and Workers’ Compensation
Customer Service
Monday – Friday 8:00am to 8:00pm ET
1-855-798-2627/1-855-797-2627 (TTY/TDD)
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Medicare Secondary Payer Overview
Medigap
• Medicare supplemental insurance is a private health insurance
policy designed to pay expenses Medicare does not pay when
Medicare is the primary payer
– Medicare Deductible
– Medicare Coinsurance Amounts
– Other Limits
http://www.medicare.gov/supplement-otherinsurance/medigap/whats-medigap.html
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Coverage Primary to
Medicare
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Coverage Primary to Medicare
Group Health Plans
• Health coverage sponsored by an employer or employee
organization for a group of employees, which possibly may
include dependents and retirees
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Self Insured Plans
Government Plans
Employee or Organizational Plans
Union Plans
Employee Health and Welfare Plans
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Coverage Primary to Medicare
Medicare Secondary Payer Conditions
• Working Aged Individual Includes:
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Age 65 or currently working with insurance coverage
Coverage through an employed spouse
Employer must have 20 or more employees
Must be entitled to both Part A and Part B
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Coverage Primary to Medicare
Medicare Secondary Payer Conditions
• Disabled Individuals Includes:
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Under age 65 entitled to Medicare due to a disability
Covered by a Large Group Health Plan (LGHP)
LHGP greater than 100 employees
Actively employed or covered as a dependent of a currently employed
person
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Coverage Primary to Medicare
Medicare Secondary Payer Conditions
• End Stage Renal Disease (ESRD) Individuals Includes:
– No Age Requirement
– Employer Group Health Plan through self or spouse, applies regardless of
group size or employee status
– First 30 months of Medicare eligibility or entitlement
http://www.medicare.gov/Publications/Pubs/p
df/10128.pdf
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Coverage Primary to Medicare
Medicare Secondary Payer Conditions
• Federal Black Lung Individuals Includes:
– Services related to Lung Disease or other conditions caused by coal mining
– U.S. Department of Labor 1-800-638-7072
http://www.dol.gov/compliance/laws/compblba.htm
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Coverage Primary to Medicare
Medicare Secondary Payer Conditions
• Veteran Administration (VA) Individuals Includes:
– Veterans chose which program in which they want to participate
– Do not submit claims to both VA and Medicare
– U.S. Department of Veteran Affairs 1-800-827-1000
http://www.va.gov/
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Coverage Primary to Medicare
Non Health Group Plans
• Medicare is secondary to all accident related claims
– Liability Insurance
– No-Fault Insurance
– Worker’s Compensation Insurance
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Coverage Primary to Medicare
Non Health Group Plans
• Liability Insurance Example
– Medicare Beneficiary is in an auto accident
– Beneficiary files a claims against the alleged responsible party and receives
payment
– Medicare is secondary to liability insurance payment
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Coverage Primary to Medicare
Non Health Group Plans
• No-Fault Insurance Example
– Driver/Beneficiary has an accident
– Driver has $5000 medical payment coverage on policy
– $5000 is considered No-Fault insurance and is primary to Medicare
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Coverage Primary to Medicare
Non Health Group Plans
• Workers Compensation Example
– Warehouse worker suffers a back injury while on the job
– All related medical bills are the primary payment responsibility of the
Workers’ Compensation insurer
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Coverage Primary to Medicare
Non Health Group Plans Conditional Payment
• Medicare payment for covered services when the responsible
insurer has not made payment with the Promptly Paid Period or
120 days within the date of service
– Liability Insurance
– No-Fault Insurance
– Workers’ Compensation Insurance
http://www.cms.gov/Medicare/Coordination-ofBenefits-and-Recovery/AttorneyServices/Conditional-PaymentInformation/Conditional-PaymentInformation.html
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MSP Claim Submission
Requirements
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MSP Claim Submission Requirements
Claim Level Reporting for MSP
• Submitting Claims to Medicare when Medicare is not the
Primary Payer:
– Must submit MSP claims electronically unless provider falls within
exception guidelines
– Medicare indicated as the secondary payer
– Insurance type indication
– Coordination of benefits (COB)
– COB adjustment amounts
– Service line information
http://www.cahabagba.com/part-b/claims2/medicare-secondary-payer/mspelectronic-billing-instructions/
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MSP Claim Submission Requirements
Electronic Claim Submission
• Loop 2000B – Subscriber Information
• Loop 2320 – Other Subscriber Information
• Loop 2430 – Line Adjudication/Adjustment Information
http://www.cahabagba.com/part-b/claims2/medicare-secondary-payer/mspelectronic-billing-instructions/
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MSP Claim Submission Requirements
1500 Paper Claim Submission
• 1500 Item/Block Information:
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Insured’s Name (4)
Patient Relationship to Insured (6)
Insured’s Address (7)
Patient Condition Relation (10)
Insured Policy Information (11)
Copy of the Primary Payer Remittance Advice must accompany the claim
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MSP Payment Calculation
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MSP Payment Calculation
Payment Model Process
• Schedule Comparison
– Medicare Secondary Payer Manual 100-05 Chapter 5, Section 40.7.3
Medicare Secondary Payment Calculation Methodology for Services
Reimbursed on Reasonable Charge or Other Basis Under Part B
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/ms
p105c05.pdf
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MSP Payment Calculation
Payment Calculation Example
• Schedule A
– Physician Charge – Primary Payer Payment = Schedule A Amount
$175.00 - $120.00 = $55.00
$175.00
$150.00
$30.00
$120.00
$175.00
$150.00
$30.00
$120.00
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MSP Payment Calculation
Payment Calculation Example
• Schedule B
– Medicare Allowable X 80% = Schedule B Amount
$125.00 X 80%= $100.00
Note
Procedure
99203
MOD
Par Amount
Non-Par
Amount
Limiting
Charge
eRX Limiting
Charge***
125.00
118.09
135.80
133.09
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MSP Payment Calculation
Payment Calculation Example
• Schedule C
– Primary Payer Allowable – Primary Payer Payment = Schedule C Amount
$150.00 - $120.00 = $30.00
$175.00
$150.00
$30.00
$120.00
$175.00
$150.00
$30.00
$120.00
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MSP Payment Calculation
Payment Calculation Example
• Schedule D
– Compares Schedule A through C
Schedule
Schedule Amount
Slide Number
A
$55.00
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B
$100.00
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C
$30.00
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• Medicare pays $30.00
– Lowest Schedule Amount
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MSP Adjustments & Overpayments
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MSP Adjustments & Overpayments
MSP Adjustment
• Top MSP Claim Adjustment Requests:
– The claim was denied, it has been determined that Medicare is primary
– The claims was processed as Medicare primary and payment was received
from another insurer
– The claims was denied and the retirement date for working aged, or last
date worked for disability was given
– IRS/SSA/Data Match – Claim was denied and Medicare should have been
primary. If Worker’s Compensation denied the claim, you must sent a
copy of the denial letter with the adjustment request
Adjustment
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MSP Adjustments & Overpayments
MSP Adjustment Form
http://www.cahabagba.com/documents/2012/02/
part-b-adjustmentform.pdf
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MSP Adjustments & Overpayments
MSP Adjustment Form Completion
• Select your state
X
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MSP Adjustments & Overpayments
MSP Adjustment Form Completion
• Provider & Beneficiary Information – Required Completion Fields
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MSP Adjustments & Overpayments
MSP Adjustment Form Completion
• Claim Detail
X
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MSP Adjustments & Overpayments
MSP Adjustment Form Completion
• Adjustment Request Information & Signature
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Medicare Secondary Payer
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Medicare Secondary Payer Tips
Part B MSP Providers
• Medicare providers and suppliers are responsible for
determining if Medicare is primary or secondary:
– Ask the Medicare Beneficiary questions
– Bill the Primary Payer first
– Include the Explanation of Benefit or Electronic Equivalent with your
claims
Medicare Secondary Payer Manual 100-05
Chapter 3:
•
Section 20.1 Obtaining Information From
Patient - General Policy
•
Section 20.2.1Beneficiary Questionnaire
http://www.cms.gov/manuals/downlods/msp
105c03.pdf
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Medicare Secondary Payer Tips
Contacting Benefits Coordination & Recovery Contractor
(BCRC)
• Providers should contact the BCRC concerning:
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Report changes to a beneficiary’s health coverage
Verify Medicare’s primary/secondary status
Report potential MSP situations
Report a beneficiary’s accident/injury
Customer Service
Monday – Friday 8:00am to 8:00pm ET
1-855-798-2627/1-855-797-2627 (TTY/TDD)
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http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/msp_fact_s
heet.pdf
http://www.medicare.gov/publications/pub
s/pdf/02179.pdf
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Resources
Medicare Secondary Payer IOM 100-05
• http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMsItems/CMS019017.html?DLPage=1&DLSort=0&DLSortDir=ascending
Medicare Secondary Payer for Provider, Physician, and Other Supplier Billing Staff
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MSP_Fact_Sheet.pdf
MLN Article SE1217
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1217.pdf
US Department of Labor
• http://www.dol.gov/compliance/laws/comp-blba.htm
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Resources
US Department of Veteran Affairs
• hhttp://www.va.gov/explore/?utm_source=adcenter&utm_medium=cpc&utm_term=veteran
%20affairs&utm_content=general-va&utm_campaign=search-national-va
Washington Publishing Company
• http://www.wpc-edi.com/reference/
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Question and Answer Session
Q&A
Provider Contact Center 1 (877) 567-7271
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