If the patient does not have an employer insurance plan that is primary to Medicare, the IVR will confirm this information. If the patient is covered under an employer insurance plan, the IVR will confirm the information and provide the effective date along with the employer insurance information. Medicare would be the secondary payer to the employer insurance plan.
However, the IVR statement “Medicare primary” does not negate the fact that the patient could have joined an MA plan that replaces traditional Medicare benefits. When the beneficiary has coverage through an MA plan, this plan is a temporary replacement of his traditional Medicare coverage. When this occurs, the patient will receive a new health insurance card from the MA plan and the traditional Medicare card will become inactive until that plan coverage is terminated.
This scenario can happen frequently and cause unnecessary claim denials because the provider’s office assumes without employer insurance and the IVR statement “Medicare Primary” that the claims should be filed to traditional Medicare. The provider should remain on the IVR and also obtain MA plan eligibility to have a complete picture of the patient’s health care coverage.
In addition to using the IVR, providers can also verify patient eligibility and claim status through an online inquiry process.
Medicare Secondary Payer (MSP)
Providers are required to file claims to Medicare using billing information obtained from the beneficiary to whom the item or service is furnished. Section 1862(b)(6) of the Social Security Act requires all entities seeking payment for any item or service furnished to complete, on the basis of information obtained from the individual to whom the item or service is furnished, the portion of the claim relating to the availability of other health insurance. Any provider who bills Medicare for services rendered to Medicare beneficiaries must determine whether Medicare is the primary payer for those services. Asking Medicare beneficiaries or their representatives questions concerning the beneficiary’s MSP status may accomplish this determination.
To conform to the law and regulations, the provider must verify MSP information prior to submitting a bill to Medicare. Verifying MSP information means confirming that the information furnished about the presence of another payer that may be primary to Medicare is correct, clear, and complete and that no changes have occurred.
The role of Medicare as the secondary payer is similar to the coordination of benefits clause in private health insurance policies. By federal law, Medicare is secondary payer to a variety of government and private insurance benefit plans. Medicare should be viewed as the secondary payer when a beneficiary can reasonably be expected to receive medical benefits through one or more of the following means:
An Employer Group Health Plan (EGHP) for working aged beneficiaries.
A Large Group Health Plan (LGHP) for disabled beneficiaries.
Beneficiaries eligible for End Stage Renal Disease (ESRD).
Veterans Affairs (VA).
A Workers’ Compensation plan.
The Federal Black Lung Program.
Any conditional primary payment(s) made by Medicare for services related to an injury is subject to recovery. A conditional payment is a payment made by Medicare for Medicare-covered services where another payer is responsible for payment and the claim is not expected to be paid promptly (i.e., within 120 days from receipt of the claim). Medicare makes conditional payments to prevent the beneficiary from using his own money to pay the claim. However, Medicare has the right to recover any payments. This includes payments that should have been paid under:
Automobile, medical or no-fault insurance.
Questions that might be asked during patient screening include:
Are you or your spouse currently working?
Are you currently receiving any type of employer insurance benefits where you work now?
Are you covered under group health care from a spouse, parent or guardian’s employer insurance plan?
· Are you receiving any type of medical care that could/should be covered under another insurance (e.g., workers’ compensation claim or liability accident)?
Do you need treatment as a result of an accident/injury/illness where another person/party should be responsible?
Additional questions that could also be asked:
Are you currently receiving benefits due to coal miner’s disease or through black lung benefits?
Are you receiving benefits through the United Mine Workers Association?
Is your injury/illness the result of a work-related accident?
Are these services related to an auto/no-fault/liability accident?
Are you a veteran and will this service be paid for by Veterans Affairs?
Have you changed from “traditional” Medicare benefits to a Medicare Advantage replacement plan?
Each of these questions will help determine Medicare’s role as an insurance payer. Should Medicare process the claim as primary, as the secondary payer, or not at all due to another payer being responsible for the service(s)?
Supplemental Insurance Benefits
A patient may elect to purchase outside supplemental insurance or retain a secondary insurance plan through some type of retirement package from a previous employer. Both types of plans pay as a secondary or supplemental insurance plan to Medicare.
In some instances Medicare claims can be automatically transferred to the supplemental insurance plan either by an automatic crossover process or a process in place for those insurance plans designated as a Medigap plan.
Supplemental insurance plans may offer an automatic crossover for those entitled to benefits, which is done through the Coordination of Benefits Contractor (COBC). The supplemental insurance eligibility is loaded into the patient’s national profile, and during claims processing the claim is automatically forwarded to the supplemental insurance for processing. This allows the provider office to file one claim and receive claim processing information from two insurance plans.
Medigap plans are privately purchased and are designed to supplement Medicare coverage as well. Some Medigap insurance plans offer the same automatic crossover benefits as supplemental insurance plans. If the Medigap insurance does not provide automatic claim transfer, the provider must indicate on each Medicare claim the patient’s Medigap insurance information in order for the processed claim to be sent to the Medigap plan.