But first, what is MSP and why is it so important?
Conditioning exercise – know the terms of the game. Let’s start with primary payers. Primary payers are those which have the primary responsibility for paying a claim. Sounds simple, right? How does this apply to MSP? Medicare does not pay for services and items that other health insurance or coverage is primarily responsible for paying. In other words, Medicare is the secondary payer when it is not responsible for paying first; when it is not the beneficiary’s primary health insurance coverage. So, remember, only in the absence of other primary insurance or coverage does Medicare remain the primary payer. Examples include accidents where the auto insurance would eclipse Medicare, workers compensation, a fall whether at home or on public property, etc.
Are there any exceptions to the MSP requirements? No and Yes.
First, no. Federal law takes precedence over state laws and private contracts. It doesn’t matter what an insurance contract or state law may claim federal law always take precedence.
Second, yes. In the following situations, Medicare may make payment, assuming Medicare covers the services and you file a proper claim.
Conditioning note: When submitting a claim to Medicare, include documentation from the other payer stating the claim was denied and/or benefits were exhausted.
OK. With this understanding, you should be in shape and in racing trim. Let’s discuss 5 tactics to completing the collection race in good time.
1. Contact the COBC (Coordination of Benefits Contractor).
You may contact the COBC to:
2. Know your responsibilities.
As a Medicare provider you should obtain billing information prior to providing services. You will need to:
3. Gather accurate data from the MSP beneficiary.
You must determine whether Medicare is the primary or secondary payer for each inpatient admission prior to submitting a bill by asking Medicare beneficiaries about other coverage. You should also inquire through HETS (HIPAA Eligibility Transaction System).
The MSP Questionnaire
CMS developed an MSP questionnaire[2] for providers to use as a guide to help identify other payers that may be primary to Medicare. The questionnaire follows a logical step-by-step sequence of Yes/No questions involving whether or not:
Race tactic: You should retain a copy of completed MSP questionnaires in your files or online for 10 years.
4. Avoid submitting a claim to Medicare without providing the other insurer’s information.
Medicare may erroneously pay the claim as primary if it meets all Medicare requirements, including coverage and medical necessity guidelines. However, if the beneficiary’s Medicare record in HETS indicates that another insurer should have paid primary to Medicare, Medicare will deny the claim, unless it may rightly pay conditionally.
5. Avoid the penalties to failure to filing correct and accurate claims with Medicare.
Medicare can fine providers, physicians, and other suppliers up to $2,000 for knowingly, willfully, and repeatedly providing inaccurate information related to the existence of other health insurance or coverage.
MSP is a serious matter you should carefully address BEFORE you file a claim. By following these five steps you will be in good shape to cross the collection finish line successfully and in good time.
[1] The term "Medicare Secondary Payer" is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the "gaps" in Medicare's coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program.
[2] Medicare Secondary Payer (MSP) Manual, Chapter 3 - MSP Provider, Physician, and Other, Supplier Billing Requirements, 20.2.1 - Admission Questions to Ask Medicare Beneficiaries.