For some providers, billing can simply be a nightmare. Despite the countless years of experience in dealing with Medicare, insurance companies, and other claim problems, many still struggle with the complexities that go into billing. As a vital component in managing a business, it is crucial to learn some of the best billing practices which have been tested by professionals in the field.

1. Eligibility verification – By pre-screening a resident/patient’s insurance a provider can know upfront what can be covered and what will not. This will decrease the number of denials a provider receives when filling claims.
2. Admissions– Define a clear set of rules and follow them. These will help the patient and family to know up front how business will be conducted. Having a clear system of handling transactions allows you to save countless hours of financial reviews.
3. Revenue cycle – Create a revenue cycle and live by it. This will help guarantee that you get paid in a timely manner. Map out each step in the billing cycle and educate all the employees involved on how to properly handle their individual roles. While an educated staff can develop these, many providers might consider it valuable to bring in an expert like an accountant to help develop this cycle.

These are just a few of the countless practices that experts have found to increase billing efficiency. For more information, contact the experts at ProClaim Partners, who can show you how to make sure your business stays productive and profitable.

Welcome to BlueFin HR’s new blog. While our fundamental principles, our reason for being, our in-depth experience and expertise, our 12-year track record, our comprehensive automated Recruiting, Applicant Tracking, and Hiring Management solutions are NOT new, BlueFin is – a revitalized and expansive web-based solutions set which will help you be the recruiting and retention champion of your organization. Our solutions will help you streamline, save money, reduce costly errors, and insure compliance. And you, your HR team, your managers, and your employees come off the winners. It doesn’t get much better than that.

Going forward, our blog postings will give you expert advice to help you meet the economic, workforce management, and regulatory challenges you face and undoubtedly will face in the future. Our blog is a conversation between and among professionals, like you, to share new insights and proven practices. It will be informative, entertaining at times, and fun. You will walk away with new insights and inspiration.

At BlueFin HR, we are excited about the future and what it can mean for all HR managers. Yours is a tough job. We can help you make it easier. We invite you to explore our website and contact us to discuss how easy it is to be a workforce management winner.

Winning the race to collect your money on time is everything. However, Medicare Secondary Payer[1] (MSP) may cause nursing home billers to trip up in their efforts to get payments as quickly as possible. Tripped too often, and providers may find themselves not quite reaching the monthly collection goal finish line. Worse yet, they may find themselves going backwards due to fines imposed for “knowingly, willfully, and repeatedly providing inaccurate information related to the existence of other health insurance or coverage.” Perhaps it’s time to get in shape regarding MSPs.

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.

• A Group Health Plan (GHP) denies payment for services because the beneficiary is not covered by the GHP;
• A no-fault or liability insurer does not pay or denies the medical bill;
• A Workers Compensation (WC)  program denies payment, as in situations where WC is not required to pay for a given medical condition; or
• A WC Medicare Set-aside Arrangement (WCMSA) is exhausted.

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:

• Verify Medicare’s primary/secondary status,
• Report changes to a beneficiary’s health coverage,
• Report a beneficiary’s accident/injury,
• Report potential MSP situations, or
• Ask questions regarding Medicare development letters and questionnaires

2. Know your responsibilities. 
As a Medicare provider you should obtain billing information prior to providing services.  You will need to:

• 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.
• For Part A, submit any MSP information on your Medicare claim using proper condition and occurrence codes on the claim.
• For Part B, submit an Explanation of Benefits (EOB) form from the primary payer on your claim with all appropriate MSP information. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process the MSP claim.

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:

• The beneficiary is receiving Black Lung (BL) Benefits
• The services are to be paid by a government research program
• Department of Veterans Affairs (DVA) has authorized and agreed to pay for your care at this facility
• The illness/injury was due to a work-related accident/condition
• The illness/injury was due to a non-work-related accident
• No-fault insurance is available
• Liability insurance is available
• The beneficiary is employed
• The spouse is currently employed
• The beneficiary has group health plan (GHP) coverage based on his or her own or a spouse's current employment
• The beneficiary has GHP coverage based on own current employment: does the employer that sponsors or contributes to the GHP employ 20 or more employees or 100 or more employees?
• The beneficiary has GHP coverage based on his or her spouse’s current employment: does the spouse’s employer that sponsors or contributes to the GHP employ 20 or more employees or 100 or more employees
• The beneficiary is covered under the GHP of a family member other than his or her spouse whose employer that sponsors or contributes to the GHP employs 100 or more employees
• The beneficiary has End Stage Renal Disease (ESRD) and has group health plan (GHP) coverage
• The beneficiary has received a kidney transplant
• The beneficiary has received maintenance dialysis treatments
• The beneficiary is within the 30-month coordination period that starts MM/DD/CCYY
• The beneficiary is entitled to Medicare on the basis of either ESRD and age or ESRD and disability
• The initial entitlement to Medicare (including simultaneous or dual entitlement) was based on ESRD
• The GHP is already primary based on age or disability entitlement

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.

Likely, this is not new to you, but I think it’s worthwhile repeating – URGENTLY - and doing something about it, if you haven’t. Time is running out for those of you who are procrastinators. By April 2013, you will no longer be able to check on a resident’s Medicare eligibility through the Common Working File (CWF).  What does this mean? It means that if you haven’t already, you should start checking Medicare eligibility through the (bear with me here) Medicare Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS). (Ah, what’s in an acronym?) HETS replaces CWF inquiries. In a way, CMS has made life much easier for billers, because with HETS you can check a beneficiary’s eligibility in real time. (For more information about HETS and how to get into the system,contact us at 877-644-2312 or info@proclaimpartners.com.)

A little background, please. CMS has simplified the eligibility checking process so that through HETS you can submit your inquiry with a real-time 270 request and receive your 271 response, a Functional Acknowledgement (999), an Interchange Acknowledgement (TA1), or a proprietary error response over a secure connection. According to the guide, “The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.” This change will likely require you to change your billing processes.

When you submit the 270 inquiry, essentially, you need only to include the following information:

• Health Insurance Claim Number (HICN)
• The Medicare beneficiary’s birth date
• The beneficiary’s complete first name
• The beneficiary’s complete last name

While the first name and birth date are optional, you will need to include at least one of them.

What information should you receive? The information includes the same you received from CWF which you need to file a claim, excepting psychiatric information.  Also it will give you additional information, such as the Part D plan number, address, and enrollment dates as well as the Medicare Advantage Organization name, address, website, and phone number. (Pretty nifty.)

Who can you talk to for help? If you have questions regarding eligibility/benefit data for Medicare Part A and Part B, you should contact your regional Medicare Administrative Contractor (MAC). For questions about Medicare Advantage (MA), Part D, eligibility/benefit and Medicare Secondary Payer (MSP) you should contact the appropriate plan(s) listed in the 271 response. You can also contact us at 877-644-2312 or info@proclaimpartners.com.

Some of the information HETS will send you will be in a format somewhat different from what you may be used to. Also, HETS will eventually be able to send Hospice information in the same format as the CWF. The HETS 270/271 Companion Guide gives you more insight into the eligibility information you will receive in the HETS 271 response. Click here for to view or download the guide.

If you are using a clearinghouse, such as ProClaim Partners, to access Medicare beneficiary eligibility information, they can also answer the questions you may have.

Question: If you are using HETS, how has this changed how you check a resident’s eligibility? Has this change helped you? If so, in what ways?