MSP claims?when billers must be detectives

By Janet Potter, CPA, MAS, Manager, FR&R Healthcare Consulting, Inc.

Medicare as Secondary Payer (MSP): the claims so many billers dread. Many MSP situations are discovered after the fact, which makes gathering the necessary information to complete them even harder. While no one can make these claims go away altogether, we can make the process easier by taking steps up front.

When the program first began, Medicare was primary to all other payers except worker’s compensation. In 1980 Congress enacted the MSP provisions to make Medicare secondary to most other insurances. There are no exceptions to the MSP rules; they take precedent over all other state and federal laws. Providers are required to screen for other insurances that are primary to Medicare, and to bill those insurances first.

Many Medicare beneficiaries have additional health insurance coverage which is primary to Medicare. Group employer health plans or retirement health benefits may still be in effect (either through their own coverage or that of a spouse) after the beneficiary has qualified for Medicare. When there is an accident involved there may be an auto or home owner’s liability or no fault policy or worker’s compensation. Some beneficiaries may have other insurance due to their medical condition such as Black Lung or end stage renal disease (ESRD).

A thorough screening for MSP policies is the biller’s best defense for avoiding tricky situations later. The earlier the MSP policy is identified, the better. It is imperative to review the HIPAA Eligibility Transaction System (HETS) prior to admission. HETS will identify any other open insurance policies. On the MSP screen, any insurance policies listed with an effective date and no termination date will be considered primary to Medicare, until those policies are closed. It is important to check HETS multiple times throughout abeneficiary’s stay, as sometimes MSP policies will appear later due to timing and notification issues by the third-party payers. You can check the HETS information at: www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/HowtoGetConnectedHETS270271.html.

A difficulty arises when an old policy is still listed as open, when it actually terminated years ago. When this situation occurs, the SNF will need to work with the resident and family to close the old policy. The beneficiary can call the Benefit Coordination Recovery Center (BCRC) formerly known as the Coordination of Benefits Contractor (COBC) with the updated information. If the beneficiary is unable to make the call personally, the facility staff can call with the beneficiary in the room. The other insurance can also update the records by submitting a request to the BCRC on its letterhead.

Providers are also required to complete an MSP questionnaire. There is no standard form, but questions to include are provided in the CMS Medicare Secondary Payer Manual, Chapter 3. Your Medicare Administrative Contractor (MAC) may also have a form. Upon admission, and readmission, the MSP questionnaire should be completed. The questionnaire must be kept on file for 10 years. The questionnaire is used not only to identify potential other payers (such as employer group health plans or liability insurance following an accident), but also to begin gathering information for billing the other insurance primary.

When another policy is discovered, that’s when the real detective work begins. Billers must investigate the plan with the beneficiary and family to determine if it is current, and then with the insurer to determine what can be billed to the plan and how.

It is very important to follow the Medicare MDS schedule for all residents including those who are MSP. If Medicare is to pay secondary or if it is later determined Medicare is primary, it is vitally important to have those required assessments completed. In addition, MSP residents should be placed in a Medicare certified bed. For example, if the primary insurance denies the claim because the policy benefits are exhausted, or other similar reason, then Medicare will pay the claim if it is for Medicare covered services and meets all other Medicare criteria. If the resident was not in a Medicare bed, that would lead to a technical denial. And if there was no MDS assessment completed, the facility will only be able to bill at the default rate.

The UB-04 for MSP claims is very similar to a regular Medicare claim, but with additional information included. Occurrence codes are required to describe the event and the date the event occurred. Also value codes and amounts which describe primary payer source and amounts paid are required. You will complete the name of the primary insurer in line 50A of the UB-04, and list Medicare as secondary payer in line 50B of the UB-04. Be sure to include the complete address information for the primary insurer listed in the Remarks section as well as an explanation code that is also required to indicate to Medicare why the primary insurance is not paying the claim. (See grids for common MSP codes.)

Some steps to follow whenever there is another payer include:

• Immediately upon determining there is a primary payer, notify the A/R manager (or other facility designee)
• Determine if the facility has a contract with the payer
• Obtain a copy of the policy when possible
• Call the payer to determine:
  • Coverage criteria
  • Benefits covered, including days available and ancillaries allowed
  • Billing requirements
  • MDS requirements
  • Preauthorization requirements
• Maintain records of all contacts with the insurance company
  • Phone calls, emails, obtaining information from their website
  • Include date and time of contact
  • Individual’s name
  • Web address and retrieval date of any information downloaded from website
• Prepare and submit the claim
  • Monitor claim status on a weekly basis
• When the claim is adjudicated
  • Record payments in accounts receivable
  • Discuss denials with appropriate facility manager
  • Notify resident/responsible party of denials
  • Determine if Medicare will pay any additional amounts
  • If claim will not be paid within 120 days, determine if a conditional payment is an option
• If additional monies are due from Medicare, bill secondary

Success with MSP claims is all about persistence, documentation, and attention to detail. While the temptation to ignore them and hope they go away is strong, resist and begin early to get the information needed to file the claims. The timely filing window is ticking and it is easy for MSP claim payments to be lost because of delays in action. Put on your detective cap right away and begin the investigation to get the claim properly paid.

BCRC Contact Info

Phone: 1-855-798-2627

TTY/TDD 1-855-797-2627

Fax: 1-405-869-3307 (address the fax to Medicare- MSP General Correspondence)

Mailing address:

Medicare ? MSP General Correspondence

P.O. Box 138897

Oklahoma City, OK 73113-8897

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