Rehab

Admission process key to accurate MSP claims

Rehab Regs, May 12, 2003

Admission process key to accurate MSP claims

You're seeing a patient at your PT practice for the first time who suffered injuries as a result of an auto accident. While the patient is 72 years old and qualifies as a beneficiary, Medicare is not the primary payer to your practice. Do you know why?

While many outpatient rehab providers may know regulations require that Medicare be considered as the secondary payer if another payer is involved, they may remain somewhat hazy on the instances under which this would occur. To others, the whole subject is a black hole that seems better left avoided. Providers should be warned, however, that when billing to the appropriate party is not performed properly (e.g., Medicare is billed as the primary insurer when instead it should have been secondary) it can wreak havoc with your reimbursement cycle.

"If you make a mistake, get it wrong, and bill Medicare as primary when it should be secondary, it can create a lot of problems," says Peter Kovacek, PT, MSA, owner of Kovacek Management Services Inc., in Harper Woods, MI. "The claim's going to be sent back to you and you may find yourself waiting another 90 to 120 days to receive payment."

First, it's critical that you understand the concept of Medicare as secondary payer, industry experts say. "When someone has two different insurers-one of which is Medicare-there are certain conditions under which Medicare is not the primary payer," Kovacek says. "In certain situations, for example, the first payer may be BlueCross Blue Shield, and Medicare is considered the secondary payer, picking up coinsurance costs. It depends upon the situation. The rules are fairly complex, yet they are very finite."

The role of Medicare as the secondary payer is similar to the coordination of benefits clauses contained within private health insurance policies, says Connie Ziccarelli, business manager for Rehab Management Solutions in Kenosha, WI. In general, Medicare is viewed as the secondary payer when it's expected a Medicare beneficiary will receive medical benefits from another insurer.

According to CMS regulations, Medicare would serve as secondary payer in the following five circumstances:

The patient's diagnosis and treatment for rehab is related to an auto accident. The primary benefits are paid by auto medical or no-fault insurance, or as a result of a settlement. Or the patient's primary benefits are covered by liability coverage.

The patient's injury and diagnosis relates to a workers' compensation claim and primary benefits are paid under the workers' compensation plan or law.

Or the patient receives the so-called "Black-Lung" benefits, and his or her diagnosis is related to this condition.

The patient is 65 or older and falls into the category of the working aged, in that he or she is still employed and is covered under a group health plan-or his or her spouse is employed and receives benefits under the plan.

The patient, who is under 65 but qualifies Medicare due to disability, receives benefits under a group health plan.

The patient receives Medicare benefits only because he or she has end-stage renal disease and is covered by a group health plan.

Providers aren't required to file a Medicare secondary claim unless they have all the information needed to file the claim. This usually means they must have the primary insurer's explanation of benefits (EOB). They would be required to file the Medicare secondary claim when they receive the EOB from either the insurer or patient. So what do you need to remember when it comes to billing? Industry experts recommend:

 Follow the basics. When providers file claims for Medicare patients covered by more than one insurer, their billing process should encompass the following, says Ziccarelli:

  • Obtain all of the pertinent information from either the patient or responsible party regarding all relevant insurers
  • Determine which insurer is primary, secondary, and tertiary
  • File claims accordingly, in order of liability
  • When filing a Medicare secondary claim, include a copy of the EOB from the primary insurer

 Differentiate responsibility. When first seeing a patient covered by Medicare, outpatient rehab providers should ask whether they have any other insurance before they submit claims to Medicare. You should ascertain this at the time services are provided, says Ziccarelli.

Stress to patients that they need to notify their health care providers-either prior to or at the time services are provided-if they have other insurance coverage.

 Don't panic. You may bill Medicare as the primary payer for a patient and later discover that, in fact, it should have been billed as a secondary payer, Ziccarelli says.

If this occurs, you will probably receive a Medicare remittance notice alerting you to the fact the patient has primary coverage.

At that point, submit the claim to the primary carrier and then bill Medicare as secondary payer. Remember to include the EOB.

In some cases, claims involving Medicare as secondary payer may be sent to a different address than where you would send claims in which Medicare is the primary payer.

You must be proactive and know this ahead of time, as instances such as these can cause payment delays, Ziccarelli says.

 Focus on the registration process. To avoid payment delays, it's important you have a clear outline of patient coverage prior to care.

At the time of patient registration, it's important that you give thorough attention to insurance coverage.

"Ask Medicare beneficiaries how the injury or ailment occurred, as this will uncover any motor vehicle accident or accident that may require third-party liability," Ziccarelli says.

"Prior to the onset of the services, review with the patient how billing will be done, and have the patient sign off on the coverage and who will be billed. This makes sure the patient is in agreement with how their claim is handled."

Editor's note: These questions are adapted from those listed in the Medicare Hospital Manual's admission section-and outpatient rehab providers who operate within different settings can likely find similar documentation in their respective Medicare manuals.

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