Master Core Curriculum

1. Master Core Curriculum Part B Basic Module 6 Medicare Secondary Payer

2. Learning Outcomes At the end of this module, participants will be able to: • describe the role of the Medicare carrier • describe the role of the Coordination of Benefits Contractor • identify MSP categories • describe claim filing requirements for secondary claim situations • explain how to submit a secondary payer claim correctly

3. What is Medicare Secondary Payer? • Program initiated in 1983 • Program developed to safeguard Medicare program dollars • Allows proper coordination between private insurers and the federal government • Situations where Medicare is NOT the primary payer

4. Benefits of MSP • National Program Savings • Increased Revenue • Reduced Beneficiary Out-of-Pocket Expense

5. The Role of the Medicare Carrier • Process claims • Answer bill questions • Conduct 1st level appeals • Accept the return of inappropriate Medicare payment

6. The Role of Coordination of Benefits Contractor • Implemented in January 2001 • Created to centralize activities that coordinate Medicare and other insurance coverage • Assist in campaign against Medicare fraud, waste and abuse under MIP • Ensure that the correct primary payer pays primary

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8. MSP Types & Categories • Working Aged • End Stage Renal Disease (ESRD) • Disability • Worker’s Compensation (WC) • Liability & No-Fault • Veteran’s Administration (VA) • Black Lung

9. MSP Claim Filing • Submit claim to primary insurer FIRST • Primary payer’s EOB is needed BEFORE Medicare pays • The EOB will contain: • Name and address of primary payer • Breakdown of charges • Primary insurer paid amount • Explanation of remark codes

10. MSP Claims…Electronically! • MSP claims can be submitted electronically • NOTE: Claims with multiple primary payers CANNOT be submitted electronically • ANSI version 4010A1 Implementation Guide • http://www.wpc-edi.com/hipaa • Primary insurance EOB does not need to be submitted • Correctly submitted claims processed FASTER than paper claims!

11. Paper Claims • CMS-1500 claim form instructions MUST be followed • http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf • Submit a complete copy of primary EOB with the claim form • Total LAST page if more than six services are submitted

12. Claim Filing Reminders • Providers and suppliers are required to determine if Medicare is primary or secondary • Obtaining this information will save you time and money • Penalties assessed for knowingly and willfully providing inaccurate information

13. Conclusion • Medicare began in 1966 to complement other benefits • Benefits to the MSP Program • Important roles for Medicare carrier and COBC • Specific billing requirements for MSP claims

14. Chapter Review • Can an individual choose Medicare as their primary insurance carrier? • No. If a patient qualifies for Medicare as secondary insurance, it will always pay secondary • No. Only Congress can set the conditions for coverage for services under the Medicare program. • No. Medicare is the secondary payer even if a private policy or state law attempts to make it primary. A state law or insurance policy provision cannot override a federal statute which establishes the opposite priority. • All of the above.

15. Chapter Review • Medicare is usually the secondary payer when a beneficiary: • Is covered by Medicaid in addition to having Medicare. • Is covered by a Medigap policy or another privately purchased insurance policy not related to any type of employment. • Is over age 65 and currently working full time at a large company. • Has only Medicare as his/her source of medical and/or hospital coverage.

16. Chapter Review • The Coordination of Benefits Contractor (COBC) is primarily responsible for: • Reporting any employment changes or other insurance coverage information for a Medicare beneficiary. • Activities related to the identification and recovery of MSP related debts. • Processing claims for primary or secondary payment. • Initial enrollment in the Medicare program.

17. Chapter Review • The federal program that allows certain qualified individuals to obtain medical services related to lung disease and other conditions caused by coal mining: • Veteran’s Administration • Black Lung • Group Health Plan • Omnibus Budget Reconciliation Act

18. Chapter References/Citations • CMS Resident & New Physician Guide 7th edition-August 2003 • CMS Medicare Secondary Payer Information Bulletin for Insurers and Employers – September 1998, February 2002 • Palmetto GBA Provider Website – MSP – May 2004 & June 2004 • CMS Medicare Website - Medicare Secondary Payer and You