Medicare Secondary Payer (MSP) Claims Investigation

Effective January 8, 2001, the COB Contractor assumed responsibility for virtually all initial MSP development activities formerly performed by Medicare intermediaries and carriers. This means the COB Contractor is charged with ensuring the accuracy and timely update of data populated on Medicare’s eligibility database regarding other health insurance that is primary to Medicare. The COB Contractor also handles MSP-related inquiries, including those seeking general MSP information, but not those related to specific claims or recoveries.

The COB Contractor is primarily an information gathering entity. A variety of methods and programs are used to identify situations in which Medicare beneficiaries have other health insurance that is primary to Medicare:

Secondary Claim Development: When a claim is submitted with an explanation of benefits (EOB) attached from an insurer other than Medicare, a questionnaire is sent to the beneficiary to collect information on the existence of other insurance that may be primary to Medicare.

Self-Report Development: A self-report covers the full spectrum of MSP situations. Any source that contacts the COB Contractor initiates this type of development process in order to address these inquiries and to assure that the information provided is accurate.

Trauma Development: When a diagnosis appears on a claim that information is received through correspondence or on a claim that indicates a traumatic accident, injury, or illness, which might form the basis of MSP, a questionnaire is sent to collect information on the existence of other insurance that may be primary to Medicare. This questionnaire may be sent to the beneficiary, provider, attorney, or insurer.

CFR 411.25: This process confirms MSP information received from a third party payer.
The goal of these MSP information-gathering activities is to identify MSP situations rapidly, thus ensuring correct primary and secondary payments by the responsible party. Providers, physicians, and other suppliers benefit from this activity because the total payments received for services provided to Medicare beneficiaries are greater when Medicare is a secondary payer to a GHP than when Medicare is the primary payer.