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?

With all that we’ve been reading about alleged LTC Medicare fraud, overbilling, claiming more services than that which were actually provided, giving incorrect treatments, or up-coding Medicare claims, it’s hard for providers not to feel like a target. Therefore, on behalf of those who are trying to do their best in a world of changing rules, retro reviews, and the dramatic expansion of diagnostic codes, we cry, “Enough already!” We want to speak out for all providers who are doing their best and are NOT trying to rip the system. We believe that the majority of providers operate with integrity and with the intent to provide service consistent with each resident’s needs. Personally, I take exception to any outcry that providers are gaming the system before all the evidence is in place – makes good headlines, but poor policymaker/provider relationships and certainly LOUSY policy.

ProClaim Partners has the opportunity to work with LTC providers managing numerous facilities across the country. Because we work directly with their billing staff and AR managers, we believe that they are doing their best to meet the real needs of their residents and are striving to make sure that the bills are clean and accurately represent the care given.

Having said that, do errors occur? Certainly. Years ago as an adult Boy Scout leader, I, along with others, maintained that scouting would be great…if it weren’t for the boys. Well, providers are in the people business employing people – fallible people. Operating a people business without the messiness of working with people would be great, but unreasonable and illogical. Despite providers’ best efforts with triple checks and even with their clinical applications screening the claims, we’ve discovered extra digits in Medicare numbers, invalid ICD-9 codes, etc.

My advice? Tell your story with claims that accurately reflect the care given and which are properly screened and scrubbed by members of your team (triple check), your clinical application, and a third-party automated claims management solution like ProClaim Partners. And tell your PR department to get off its duff and shout from the rooftops every day the wonderful things your facility and company are doing for the residents you serve, particularly if you are providing services to higher acuity residents. Tell your story. NO, tell your residents’ stories. It’s great press and a great buffer to the possible regulatory scrutiny and bad press that you could encounter in the future.  

Procurement automation has opened the door to opportunities not only to reduce costs, but to improve efficiency and to ensure quality consistency. Think of it this way, as the one responsible for your company’s purchasing practices, you have a lot on your plate. It’s one thing to negotiate purchasing contracts with vendors for all your food, medical supplies, office supplies, housekeeping supplies, and other supplies purchases. It’s another to make sure that those of your organization who place the orders actually receive the benefits from all your hard work. This is where Order Guide Management (OGM) comes in. In short, OGM is the ability to control which products your users have access to according to the terms negotiated.

Because of automated OGM,

• You can ensure that purchasing complies with the contracts painstakingly negotiated, because the users only see what you want them to see when they are preparing their orders.
• Users can more readily find the products they need whether they order them on a recurring basis or only occasionally.
• Users will purchase products that are of the quality you expect and insist upon.
• Your company can also maximize product rebates that your vendors may offer.

OGM is not new, but Procurement Partners is taking this principle to the next level with an enhanced Order Guide Management tool which will be released in the fall of 2012. Our automated and configurable procurement portal is like no other in the industry.

The key benefits of our new OGM tool:

• It can be used for all vendors from food, to medical supplies to office supplies and more.
• Flexibility – a single guide can be used for multiple ordering locations, multiple vendors, and/or multiple job roles.
• Multiple guides can be assigned with priorities defining which order guide attributes take precedence. 
• As the application administrator you have complete control. You don’t have to contact us to make changes.

To learn more, visit us during the AHCA/NCAL 63rd Annual Convention and Expo, booth #1319 or during the 2012 LeadingAge Annual Meeting and Exposition, Prime Care Technologies booth #530. We can introduce you to this outstanding tool and other features of our exceptional automated procurement application.

The headlines in the long term care media continue to highlight RACs audits, claims scrutiny, and claims denial. Further, at a time when sequestration threatens to reduce Medicare reimbursement by as much as 1.8%, revenue cycle management needs to have the constant attention of all providers every day. Of course, the first thing to do is to minimize the risk of denied claims as well as rejected claims.

Even if you are able to withstand an audit, assuming the clinical documentation supports the claims submitted, you still run the risk of poor cash flow management if your claims are rejected because of inadequate or outmoded claims preparation and “scrubbing” processes. Just as it’s important to “get it right the first time” by having the documentation to support your claims, you need to get it right when preparing the claims. In our free download position paper, Five Most Common Billing Errors, we offer insights into ways to avoid billing errors, improper diagnosis codes, invalid hospital stay dates, incorrect service dates, and etc. What we’re talking about in this post is taking your claims submission process to a higher level through claims automation. Claims automation can help by consolidating the claims submission and management process through one portal. This is the premise behind the ProClaim Partners clearinghouse. It’s a one-stop-shop for scrubbing, correcting, submitting, and monitoring claims as well as receiving payment notifications all in one place. You no longer have to trouble with multiple portals or applications.

Designed for long term care providers, the ideal enterprise-class portal will enable you to centrally monitor and manage all claims before and after they are submitted. From a central home page or dashboard, depending on the permissions/security levels you configure, you can review information and take action at a corporate, regional, or facility level. You can check for errors and clean them up before submitting the claims. The system’s scrubber, which constantly updates itself through its evolving database, can search for errors and omissions according to each payer’s rules. Within the portal you have the opportunity to make corrections in a number of ways according to your preferred workflow and internal policies. You can use the Search function to research claims and where they are in the submission-payment cycle.

You even have access to DDE and multiple MACs log-ins through this portal. While you can make corrections in the DDE, our clearinghouse lets you correct errors within the portal itself.

Other features allow you to stay on top of the revenue cycle for all payers. For example, your claims can be loaded into the system conveniently either via FTP or frequent data sweeps determined by you. Once the system receives the 835 payment notices, it sends emails to those you’ve designated to receive them.

To avoid unnecessary delays in payment, getting the claims submission process right the first time is critical for long term care providers. Visit us at our booth, #1418, during the AHCA/NCAL 63^rd Annual Convention and Expo or during the 2012 LeadingAge Annual Meeting and Exposition, Prime Care Technologies, booth #530, We can show how you can accelerate payments, increase collections, and reduce DSO. It’s the right thing to do.