Medicare as Secondary Payer

When a patient has Medicare and another health plan, it is necessary for the provider to make every attempt  to try to identify whether Medicare should be billed as the primary carrier. This is for all services rendered (or items delivered to a Medicare beneficiary.This can be done usually by contacting the MAC through their automated system or having the patient fill out a form such as this one:

https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Downloads/CMS-Questionnaire.pdf

If Medicare is not the primary payer, the provider must bill the other insurance payers before billing Medicare. The provider must submit a Medicare Secondary Payer (MSP) claim even if the primary payer made payment in full. This is done in case the “other plan” attempts to recoup monies from the provider at a later date. It would show timely billing to Medicare so that Medicare would possibly pay in case the other monies had to be returned at a later date.

When a Medicare beneficiary’s insurance has changed, it is up to the beneficiary to contact Medicare so that the changes can be made to the Medicare master file. Though the provider can attempt to update this information; the patient will be responsible for the bill if they have not assumed this responsibility, and followed up to make sure that the changes are reflected at Medicare.

When is Medicare considered primary or secondary?

The following link is an excellent (and updated) resource to help determine when a provider bills a health plan or Medicare as primary or secondary.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/msp_fact_sheet.pdf

 

When submitting an MSP claim, the following fields MUST be filled out:

Item 4: If insurance primary to Medicare, list name of insured. When insured and patient are the same, enter “SAME”

Item 6: Check appropriate box for patient’s relationship to insured

Item 7: Enter insured’s address and telephone number. When address is the same as patient’s, enter “SAME”

Item 10a: Is patient’s condition related to employment? Yes/No

Item 10b: Is patient’s condition related to auto accident? Yes/No

If answer=yes, include the two digit state code under Place

Item 10c: Is patient’s condition related to other accident? Yes/No

Item 11: Enter insured’s policy or group number

Item 11a: Enter insured’s eight-digit birth date and sex if different from item 3

Item 11b: Enter employer’s name, if applicable

Item 11c: Enter nine digit payer ID for primary insurer or complete primary payer’s program/plan name

Conditional Payments

Under Medicare Secondary Payer law, Medicare does not pay for items or services that payment has been, or may reasonably be expected to be, made through a no-fault or liability insurer or through Workers’ Compensation. Medicare may consider a conditional payment when there is evidence that the primary plan does not pay promptly, conditioned upon reimbursement back to Medicare when the primary plan does pay.

(This means that Medicare would have to be repaid if payment finally did come through from a Workers’ compensation or a no-fault liability insurer.) The Benefits Coordination & Recovery Center( BCRC) is the organization responsible for recovering conditional payments when there is a settlement, judgement, award or other payment made. When the BCRC has information concerning a potential recovery situation; it will identify the affected claims and begin recovery activities.

 

For more information on Medicare, please go to www.medicalbillingstudycourse.com and look at the complete and updated courses available for medical billers.

*Please refer to the guidelines from your MAC as they frequently change and there are processes that one needs to go through to do this correctly.

** this article is not intended to be used as legal advice. If you are uncertain of any information in this article, we suggest that you seek legal counsel.