Medicare Secondary Payer (MSP) NCHFMA 2014

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1 Medicare Secondary Payer (MSP) NCHFMA

2 Disclaimer The information provided in this presentation was current as of 1/10/2014. Any changes or new information superseding the information in this presentation are provided in articles with publication dates after 1/10/2014 posted on our website, All CPT codes, descriptors and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply. All CPT Codes and indications are noted where applicable. 2

3 Agenda Medicare Secondary Payer (MSP) Overview Who Pays First? MSP Questionnaire Coordination of Benefits Contractor (COBC) Medicare Secondary Payer Recovery Contractor (MSPRC) Conditional Billing Common Billing Errors & FAQs 3

4 Medicare Secondary Payer Overview 4

5 Medicare Secondary Payer Overview Section 1862 (b)(2)(a) of the Social Security Act prohibits Medicare from making payment if the payment has been made or can reasonably be expected to be made promptly by a third party This means that under certain conditions Medicare pays secondary to insurance plans and programs 5

6 Medicare Secondary Payer Overview If payment has not been made or cannot be expected to be made promptly by a workers compensation plan, liability insurance, or no-fault insurance, Medicare may make a conditional payment, under some circumstances, subject to Medicare payment rules 6

7 Medicare Secondary Payer Overview What are the benefits? National program savings Increased provider, physician, and other supplier revenue Avoidance of Medicare recovery efforts 7

8 Medicare Secondary Payer Overview MSP Billing Codes Description Payer Code Value Code Billed Working Aged A 12 End Stage Renal Disease (ESRD) B 13 Conditional Payment C Appropriate Value Code for Primary Payer No-Fault D 14 Workers Compensation E 15 Federal Black Lung H 41 Veteran Affairs I 42 Disability G 43 Liability L 47 8

9 MSP Questionnaire 9

10 MSP Questionnaire What is a MSP Questionnaire? CMS developed an MSP questionnaire for providers to use as a guide to help identify other payers that may be primary to Medicare. This questionnaire is a model of the type of questions you should ask to help identify MSP situations. Refer to the MSP questionnaire in the Medicare Secondary Payer Manual, Chapter 3, Section at on the CMS website. 10

11 MSP Questionnaire The questionnaire contains questions that can be used to ask Medicare beneficiaries upon each inpatient and outpatient admission. This questionnaire is a model of the type of questions that may be asked to help identify Medicare Secondary Payer (MSP) situations. 11

12 MSP Questionnaire Providers are required to determine whether Medicare is a primary or secondary payer for each inpatient admission of a Medicare beneficiary and outpatient encounter with a Medicare beneficiary prior to submitting a bill to Medicare. Providers should retain a copy of the completed MSP questionnaire for 10 years. 12

13 MSP Questionnaire For sample questions please refer to: Internet Only Manual (IOM) Medicare Secondary Payer Manual, Publication 100-5, Chapter 3, Section

14 Who Pays First? 14

15 Who Pays First? If the Beneficiary Situation Who Pays First? Pays Second Is covered by Medicare and Medicaid Entitled to Medicare and Medicaid Medicare Medicaid, but only after other coverage (such as employer group health plans) has paid Is 65 or older and covered by a group health plan because the beneficiary or their spouse is still working Entitled to Medicare The employer has 20 or more employees The employer has less than 20 employees Group health plan Medicare Medicare Group health plan Has been in an accident where nofault or liability insurance is involved Entitled to Medicare No-fault or liability insurance for services related to accident Medicare 15

16 Who Pays First? If the Beneficiary Situation Who Pays First? Pays Second Is covered under workers compensation because of a jobrelated illness or injury Entitled to Medicare Workers compensation for services related to workers compensation claim Usually doesn t apply. However, Medicare may make a conditional payment. Has black lung disease and iscovered under the Federal Black Lung Benefits Program Entitled to Medicare and the Federal Black Lung Benefits Program The Federal Black Lung Benefits Program for services related to black lung Medicare 16

17 Who Pays First? 17

18 Coordination of Benefits Contractor 18

19 Coordination of Benefits Contractor (COBC) THE COBC became effective January 8, Handles the initial development of MSP records for all Medicare contractors. Is responsible for updating and maintaining all MSP records in the Common Working File (CWF). 19

20 Coordination of Benefits Contractor How do you contact the COBC Contractor? Providers should contact the COBC at for assistance. Written correspondence should be sent to the COBC at: Medicare - Coordination of Benefits P.O. Box Detroit, MI

21 Coordination of Benefits Contractor When to Contact the COBC: To report employment changes, or any other insurance coverage information To report a liability, auto/no-fault, or workers compensation case To ask a general MSP questions. To ask a questions regarding the MSP letters and questionnaires (i.e. IEQ and Secondary Claim Development (SCD) questionnaires.) 21

22 Coordination of Benefits Contractor When to Contact your MAC Questions regarding Medicare claim or service denials and adjustments Questions concerning how to bill for payment Processing claims for primary and secondary payment Accepting the return of inappropriate Medicare payment 22

23 Coordination of Benefits Contractor What are the provider Responsibilities? Gather accurate MSP data to determine whether or not Medicare is the primary payer by asking Medicare beneficiaries, or their representatives, questions concerning the beneficiary s MSP status. Bill the primary payer before billing Medicare, as required by the Social Security Act. Submit any MSP information on your Medicare claim using appropriate codes on the claim. 23

24 MSPRC Contractor 24

25 Medicare Secondary Payer Recovery Contractor (MSPRC) The MSPRC protects the Medicare trust fund by recovering payments Medicare made when another entity had primary payment responsibility. The MSPRC accomplishes these goals under the authority of the Medicare Secondary Payer (MSP) Act. Primary payer as part of Non-Group Health Plan (NGHP) claim which includes, but is not limited to Liability insurance (including Self- Insurance), No- Fault insurance, and Workers Compensation. The MSRC does not pursue supplier, physician, or other provider recovery. 25

26 Medicare Secondary Payer Recovery Contractor (MSPRC) If a GHP is the proper primary payer, Medicare will seek recovery from the Employer and GHP. This type of recovery is now performed by Medicare s Commercial Repayment Center (CRC). No action is required by the beneficiary when the GHP is the proper primary payer. 26

27 Medicare Secondary Payer Recovery Contractor (MSPRC) Commercial Repayment Center (CRC) Effective May 13, 2013, all Group Health Plan (GHP) recovery related refund checks, correspondence, and telephone inquiries should be directed to Medicare's Commercial Repayment Center (CRC). 27

28 Medicare Secondary Payer Recovery Contractor (MSPRC) Commercial Repayment Center (CRC): By Mail: Medicare Commercial Repayment Center PO BOX Orange Ave. Cleveland, OH By Telephone: (Toll Free) (TTY) By Fax:

29 Medicare Secondary Payer Recovery Contractor (MSPRC) Only Beneficiaries/Representatives are able to contact MSPRC to update/close value codes 14, 15, and 47 files. Value Code Description 14 No Fault 15 Workers Compensation 47 Liability 29

30 Conditional Billing 30

31 Conditional Billing What is Conditional Billing? If payment has not been made or cannot reasonably be expected to be made promptly by workers compensation, liability insurance (including selfinsurance), or no-fault insurance, Medicare may make conditional payments. Conditional payments are subject to repayment when the primary plan makes payment. 31

32 Conditional Billing Promptly Promptly means payment within 120 days after receipt of the claim (for specific items and services) by the no-fault insurance or WC carrier. The date of service for specific items and service must be treated as the claim date when determining the promptly period. Inpatient services, the date of discharge must be treated as the date of service when determining the promptly period. 32

33 Conditional Billing Promptly For liability insurance (including self-insurance), promptly means payment within 120 days after the earlier of the following: The date a general liability claim is filed with an insurer or a lien is filed against a potential liability settlement; or The date the service was furnished or, in the case of inpatient hospital services, the date of discharge. The "Medicare Secondary Payer (MSP) Manual" ( Guidance/Guidance/Manuals/downloads/msp105c01.pdf), 33

34 Conditional Billing When will Medicare make a conditional payment? The provider has filed a proper claim under the primary plan and the plan denies the claim in whole or in part There is information on the claim that indicates the physician, provider or other supplier sent the claim to the no-fault insurer, WC or liability entity first; and There is information on the claim that indicates the liability insurer (including the self insurer) did not make payment on the claim during the promptly period. 34

35 Conditional Billing Submitting a conditional claim to Medicare Typeof Insurance No- Fault/Liability Workers Compensation GHP Value Code Value Amount OccurrenceCode 14 or 47 $0 01 Auto Accident & Date 02-No fault Insurance Involved& Date 03-Accident/Tort Liability & date 24 Date Insurance Denied 15 $0 04-Accident/Employment & date 24- Date Insurance Denied 12,13, or 43 $0 24- Date Insurance Denied Condition Code 02- Condition is Employment Related 35

36 Conditional Billing When will Medicare not make a conditional payment? It is alleged that the GHP is secondary to Medicare The GHP limits its payment when the individual is entitled to Medicare. The services are covered by the GHP for younger employees and spouses but not for employees and spouses age 65 or over 36

37 Conditional Billing Things to remember: Do not submit conditional payment claims as placeholder claims Do not submit a conditional payment claim because the beneficiary refused to cooperate 37

38 Common Billing Errors 38

39 Common Billing Errors Some of the common MSP claim errors are: Not verifying if there is an open MSP record prior to billing Medicare Making sure that the Common Working File (CWF) is updated with the correct information The name of the insurer is not identical to the information on CWF Adding correct remarks to the claim Using the proper value codes, condition codes and occurrence codes on the claim 39

40 Common Billing Errors 40

41 Common Billing Errors 41

42 Common Billing Errors 42

43 Common Billing Errors Using the correct adjustment condition code Used when Medicare originally processed a claim as primary and the provider is submitting a primary D7 payment made by another payer. D8 Used when Medicare originally processed a claim as secondary or cost avoided (rejected) the claim for MSP and the provider is submitting information that shows Medicare should be the primary payer. 43

44 Common Billing Errors Understanding Status/Location R B7516 Providers may receive reason code An adjustment is being processed against a record in a post pay location. Claim needs to be in a finalized status before making an adjustment. Please wait and refile. Claims appearing on remits in S/LOC R B7516 are not finalized and must remain in in this S/LOC for 75 days to become final. Reference: Publication , Medicare Secondary Payer Manual, Chapter 5, Section , B 44

45 Common Billing Errors Value Code 44: Reported when a provider agrees to accept a specific amount from the primary insurer for services provided and the amount reimbursed is less than the contract amount. Contracted amount is used in Medicare s MSP payment calculation to determine if a secondary payment is due. 45

46 Common Billing Errors Value Code 44 Only report value code 44 if: A balance is due from the patient and provider has a contractual agreement with the primary payer. The amount received is less than total charges, or The amount received from the primary payer is less than the contracted amount Do not report value code 44 if it is more than or equal to the total submitted charges 46

47 Common Billing Errors Value Code 44 Represents the Obligated to Accept as Payment in Full (OTAF) or total allowed amount from primary insurer s Explanation of Benefits (EOB) Coinsurance or deductible due from the patient Value Code 12,13, 43 Submit the value code that represents your MSP type followed by the actual amount of your payment. 47

48 Common Billing Errors Example of Value Code 44 Provider submitted a claim to the disability primary insurer for a claim totaling $550. Medicare interim payment (Medicare s covered amount) = $500 The provider contractual agreement (OTAF) = $450 as payment in full Primary Payer deductible amount = $50 Primary Payer payment amount= $400 Value code 44 = $ (The total amount the provider is contracted to accept) Value Code 43 = $ (primary payment) 48

49 Common Billing Errors Condition Code 08 Use when a beneficiary will not provide other insurance information. Condition code 08 flags the COBC for development of the other insurance information. Do not include accident occurrence codes or value codes with condition code 08. Enter all available information in Remarks, including the refusal or unwillingness to cooperate. Submit claim as Medicare primary unless there is an open MSP record on the CWF. 49

50 Frequently Asked Questions (FAQS) 50

51 FAQs Q: How does a provider submit a claim to Medicare when the primary payer does not make any payment at all for a valid reason such as the primary payer s total payment amount was applied toward the plan s deductible? A: If a provider receives zero payment from the primary payer when the payment was applied to the deductible, then the claim must be submitted to Medicare with all appropriate MSP codes. The claims processing system will process the claim according to the MSP regulations and in accordance with the information that is entered in the CAS. 51

52 FAQs Q: What is the difference between submitting Medicare claims electronically and DDE. A: Submitting a claim "electronically" means that it is submitted using a batch file software in the American National Standard Institute (ANSI) ASC X12N 837 format. DDE, or direct data entry, means that the claim is entered directly into the Fiscal Intermediary Standard System. 52

53 FAQs Q: My clearinghouse told me that I have to contact the primary insurer and instruct them to forward the explanation of benefits (EOB) electronically to MSP. Is this correct? A: No, this is not correct. When filing your MSP claims electronically, it is not necessary to provide the explanation of benefits (EOB) from the primary carrier. This information should be transmitted to MSP within your electronic claim.please refer to the 5010 Professional Implementation Guide (IG) for additional instructions. This guide is available for purchaseat 53

54 FAQs Q:What required "claim change condition code" do I use when adjusting a denied or rejected claim to make Medicare the secondary payer? A:You must use a condition code D7 54

55 FAQs Q:MSP claims must now be submitted on a line level. Why is that? A:Medicare's potential secondary payment is based on several things. They include adjustments made by the primary payer which, for example, explain why a line was denied by the primary payer. This is reflected by the Claim Adjustment Reason Code (CARC) used by the Primary Payer on their Explanation of Benefits (EOB). This CARC code must be entered on the same line level when submitted to Medicare. Depending on the CARC code, Medicare may or may not make a payment. Refer to CMS Change Request (CR)

56 FAQs Q: My claims are being returned with the Reason Code Why is this happening? A: See CR Business Requirement states that when the Contractual Obligation (CO) that is calculated by FISS based off the CARC codes amount does not match the Value Code (VC) 44 amount, the claim will be returned. Example: When the claim will be returned with Reason Code The VC 44 is stating that the Obligated to Accept (OTAF) amount is $2, However, when the CO 45 (Provider discount) is subtracted from the billed amount, the amount is $ ($ $ =$ ) The $ and $ do not match, therefore the claim will be returned. 56

57 FAQs Q: Are we required to submit a claim to Medicare if the primary payer paid the claim in full? A: You are required to submit all inpatient claims, and outpatient claims needed to satisfy the Part B deductible. However, in case future changes are required, we recommend that all Part B services are submitted to avoid timely filing issues. The claims should be filed as covered claims, but will be processed without payment. 57

58 FAQs Q: Why is my claim being rejected for an open Non- Group Health Plan when my service is unrelated? A:The diagnosis code submitted on the claim is either matching or appears to be related to the open Non-GHP. 58

59 FAQs Q: If a primary payer retroactively recoups after years, we would send the claim back to Medicare. Medicare denies the claim for timely filing. We request a timely filing extension with documentation. The timely filing extension is denied. Why? A: The CMS Medicare Claims Processing Manual (Pub ), chapter 1, section , contains what conditions contractors will allow for exceptions to and extensions of timely filing requirements. The exceptions include: Administrative Error, Retroactive Medicare Entitlement, Retroactive Medicare entitlement involving State Medicaid Agencies, Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization. 59

60 Thank You 60

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