Billing & Coding - Section 3: Medicare Secondary Payer

Question 1

When Medicare began in 1966, it was the primary payer for all claims, except for what?

Answer 1

Workers Comp
Federal Black Lung benefits
Veteran’s Administration (VA)

Question 2

In ____, Congress passed legislation that made Medicare the secondary payer to certain primary plans in an effort to shift costs from Medicare to the appropriate private sources of payment

Answer 2

1980

Question 3

In 1980, Congress passed legislation that made Medicare the secondary payer to certain primary plans. Why was this done?

Answer 3

To shift costs from Medicare to the appropriate private sources of payment

Question 4

The term generally used when the Medicare program does not have primary payment reponsibility (i.e., when another entity has the responsibility for paying before Medicare)

Answer 4

Medicare Seconday Payer

Question 5

How have the MSP provisions protected Medicare trust funds?

Answer 5

By ensuring that Medicare doesn’t pay for items and services that certain health insurance or coverage is primarily responsible for paying

Question 6

The Centers for Medicare and Medicaid Services (CMS) enforcement of MSP provisions saved the Medicare Program approximately $____ in Fiscal Year 2018

Answer 6

$8.5 billion

Question 7

Billing a primary plan before Medicare may provide you with ____ reimbursement rates

Answer 7

Better

Question 8

Coordinated health coverage may ____ the payment process and ____ administrative costs

Answer 8

Expedite

Reduce

Question 9

Filing claim correctly the first time prevents future Medicare ____ efforts on claims

Answer 9

Recovery

Question 10

The MSP provisions apply to situations when Medicare is not the beneficiary’s ____ health insurance coverage

Answer 10

Primary

Question 11

True or False:

Medicare statute and regulations require that all entities that bill Medicare for items or services rendered to Medicare beneficiaries must determine whether Medicare is the secondary payer for those items or services

Answer 11

False; primary payer

Question 12

Primary payers are those that have the ____ responsibility for paying a claim.

Answer 12

Primary

Question 13

Does Medicare remain the primary payer for beneficiaries who are not covered by other types of heatlh insurance or coverage?

Answer 13

Yes

Question 14

Primary payers must pay a claim ____

Answer 14

First

Question 15

Medicare pays ____ for beneficiaries in the absence of other primary insurance or coverage

Answer 15

First

Question 16

True or False:

Medicare never pays first when the beneficiary has other insurance coverage

Answer 16

False; may pay first

Question 17

____ ____ ____ help ensure Medicare payments are made in the proper order by being knowledgeable of and participating in Coordination of Benefits processes

Answer 17

Responsible Reporting Entities

Question 18

What is the purpose of Coordination of Benefits?

Answer 18

To identify the other insurance benefits available to a Medicare beneficiary, and to coordinate the payment process to prevent mistaken payment of Medicare benefits

Question 19

Are Required Report Entities required to report information about certain persons they insure to the Benefits Coordination and Recovery Center?

Answer 19

Yes

Question 20

After the Required Reporting Entities report required information about certain person their insure, to the Benefits Coordination and Recovery Center, what will the BCRC do?

Answer 20

Check to see if any of these persons also have Medicare coverage

Question 21

If the BCRC determines that a person has Medicare coverage, what will happen?

Answer 21

The employe’s insurance will be primary to Medicare and an MSP occurence will be created

Question 22

For Medicare programs to work effectively, ____have a significant responsibility for the collection and maintenance of patient information.

Answer 22

Providers

Question 23

Providers must ask beneficiaries questions to secure ____ and ____ information

Answer 23

Employment and insurance

Question 24

Providers have a responsibility to indentify payers other than Medicare so that incorrect ____ and ____ are minimized

Answer 24

Billing and overpayments

Question 25

Providers must determine if ____ is the primary or secondary payer; therefore, the beneficiary must be queried about other possible coverage that may be primary to Medicare

Answer 25

Medicare

Question 26

True or False:

Failure to maintain a system of identifying other payers is viewed as a violation of the provider agreement with Medicare

Answer 26

True

Question 27

The patient must respond to MSP claims development letters in timely manner to ensure what happens?

Answer 27

Correct payment of their Medicare claims

Question 28

It is important for a patient to be aware that changes in ____, including retirement and changes in health insurance companies, may affect your claims payment

Answer 28

Employment

Question 29

When a patient receives health care services, who should they tell about any changes in their health insurance due to their, their spouse’s, or their family member’s current employment or coverage changes?

Answer 29

Their doctor, other providers, and BCRC (benefits coordination and recovery center)

Question 30

A patient should contact the ____ if they, or an attorney on their behalf, takes legal action for a medical claim

Answer 30

Benefits coordination and recovery center

Question 31

A patient should contact the BCRC if they are involved in a ____ accident

Answer 31

Automobile

Question 32

A patient should contact the BCRC if they are involved in a ____ ____ case

Answer 32

Workers comp

Question 33

Employers must ensure that their plans identify what in relation to MSP?

Answer 33

Those individuals to whom the MSP requirement applies

Question 34

Employers must ensure that their plans provide for proper ____ payments where by law Medicare is the secondary payer

Answer 34

Primary

Question 35

Employers must ensure that they do not discriminate against employees and employees’ spouses within what 3 groups?

Answer 35

1) Age 65 or older
2) Who suffer from permanent kidney failure
3) Disabled Medicare beneficiaries for whom Medicare is secondary payer

Question 36

As a Medicare provider, you must determine whether Medicare is the ____ or ____ payer for each inpatient admission or outpatient encounter prior to submitting a claim to Medicare

Answer 36

Primary or secondary

Question 37

As a Medicare provider, you must determine whether Medicare is the primary or secondary payer for each ____ ____ or ____ ____ prior to submitting a claim to Medicare

Answer 37

Inpatient admission or outpatient encounter

Question 38

As a Medicare provider, you must determine whether Medicare is the primary or secondary payer for each inpatient admission or outpatient encounter ____ to submitting a claim to Medicare

Answer 38

Prior

Question 39

How can providers determine if Medicare is the primary or secondary payer for each inpatient admission or outpatient encounter prior to submitting a claim to Medicare?

Answer 39

By asking Medicare beneficiaries about other coverage

Question 40

Are RHCs considered Part A or Part B providers?

Answer 40

RHCs and FQHCs are Medicare Part B providers

Question 41

If a patient presents at the RHC/FQHC with Medicare Part A ONLY, they are considered “____-____” in the RHC or FQHC

Answer 41

Self-pay

Question 42

Which Medicare part are physician’s services covered by?

Answer 42

Part B

Question 43

Which Medicare part is the below covered by?

Services and supplies (including drugs and biologicals which are not usually self-administered by the patient) furnished as an incident to a physician’s professional service, of kinds which are commonly furnished in a physician’s office and are commonly either rendered without charge or included in the physicians’ bills

Answer 43

Part B

Question 44

Which Medicare part is the below covered by?

Hospital services (including drugs and biologicals which are not usually self-administered by the patient) incident to physicians’ services rendered to outpatients and partial hospitalization services incident to such service

Answer 44

Part B

Question 45

Which Medicare part is the below covered by?

Diagnostic services which are: ( i) furnished to an individual as an outpatient by a hospital or by others under arrangements with them made by a hospital, and (ii) ordinarily furnished by such hospital (or by others under such arrangements) to its outpatients for the pu rpo se of diagnostic study

Answer 45

Part B

Question 46

Which Medicare part is the below covered by?

Outpatient physical therapy services, occupational therapy services, and speech-language pathology services

Answer 46

Part B

Question 47

Which Medicare part is the below covered by?

Rural health clinic services and federally qualified health center services

Answer 47

Part B

Question 48

As a Part B provider (i.e., physicians and suppliers), you should follow the proper claim rules to obtain ____ information, such as group health coverage through employment or non-group health coverage resulting from an injury or illness

Answer 48

MSP

Question 49

As a Part B provider (i.e., physicians and suppliers), you should inquire with the beneficiary at the time of the visit if he/she is taking ____ action in conjunction with the services performed

Answer 49

Legal

Question 50

As a Part B provider (i.e., physicians and suppliers), you should submit an ____ form with all appropriate MSP information to the designated carrier. If submitting an ____ claim, provide the necessary fields, loops, and segments needed to process an MSP claim

Answer 50

MSP

Electronic

Question 51

Part B providers (physicians, practitioners, and suppliers) gather accurate MSP data to determine if Medicare is the primary payer through what means?

Answer 51

Asking Medicare beneficiaries, or their representatives, for MSP information

Question 52

Part B providers (physicians, practitioners, and suppliers) bill the primary payer ____ billing Medicare

Answer 52

Before

Question 53

Part B providers (physicians, practitioners, and suppliers) submit an ____, or remittance advice, from the primary payer with your Medicare claim, with all appropriate MSP information

Answer 53

EOB

Question 54

Part A providers (hospitals) use the MSP Questionnaire during the ____ process to gather accurate MSP data to determine if Medicare is the primary payer by asking Medicare beneficiaries or their representative

Answer 54

Admission

Question 55

Part A providers (hospitals) bill the ____ payer before billing Medicare

Answer 55

Primary

Question 56

Part A providers (hospitals) submit any MSP information on your ____ claim using proper payment information, value codes, condition and occurrence codes, etc.

Answer 56

Medicare

Question 57

True or False:

It is required to provide the MSP Questionnaire to Medicare beneficiaries

Answer 57

False; it is required to ask MSP questions at each encounter but you do not have to use the questionnaire

Question 58

Why should the CMS questionnaire be used?

Answer 58

To determine the primary payer of the beneficiary’s claims

Question 59

The CMS questionnaire consists of ____ part and lists questions to ask Medicare beneficiaries

Answer 59

6

Question 60

MSP questions must be asked at which frequency?

Answer 60

At each visit/encounter

Question 61

What is the exception to asking MSP questions at each visit/encounter?

Answer 61

The exception of policies regarding hospital lab services, recurring patient services, and Medicare+Choice organization members

Question 62

Using the CMS questionnaire as a guide to help identify other payers that may be primary to Medicare, begin with part 1. Ask the patient each question in ____

Answer 62

Sequence

Question 63

True or False:

There may be situations where more than one insurer is primary to Medicare (e.g., Black lung program and group health plan)

Answer 63

True

Question 64

There are programs under which payment for services is usually excluded from both primary and secondary Medicare payments. What are those programs?

Answer 64

Veteran’s Administration

Federal Black Lung

Question 65

Medicare does not pay for the same services covered by ____ benefits

Answer 65

Veteran’s Administration

Question 66

Medicare does not pay for services covered under the Federal Black Lung Program. However, if a Medicare-eligible patient has an illness or injury not related to ____ ____, the patient may submit a claim to Medicare

Answer 66

Black lung

Question 67

Patient is 65 or older and covered by a group health plan (GHP) through current employment or spouse’s current employment. The individual is entitled to Medicare, and the employer has less than 20 employees. Who pays first and second?

Answer 67

Medicare first, GHP second

Question 68

Patient is 65 or older, and covered by a GHP through current employment or spouse’s current employment. The individual is entitled to Medicare. The employer has 20 or more employees, or the employer is part of a multi-employer group with at least one employer employing 20 or more individuals. Who pays first and second?

Answer 68

GHP first, Medicare second

Question 69

Patient is 65 or older, has an employer retirement GHP, and is not working. The individual is entitled to Medicare. Whos pays first and second?

Answer 69

Medicare first, retiree coverage second

Question 70

Patient is under 65, disabled, and covered by GHP through his or her current employment or through a family member’s current employment. The individual is entitled to Medicare. the employer has less than 100 employees? Who pays first and second?

Answer 70

Medicare first, GHP second

Question 71

Patient has end-stage renal disease and GHP coverage was the primary plan prior to the individual becoming eligible and entitled to Medicare based on ESRD. First 30 months of Medicare eligibility or entitlement. Who pays first and second?

Answer 71

GHP first, Medicare secondary

Question 72

Patient is covered under Workers Comp because of a job-related illness or injury. The individual is entitled to Medicare. Who pays first and second?

Answer 72

WC for health care items or services related to job-related illness or injury pays first, Medicare pays second

Question 73

Patient was in an accident or other situation where no-fault or liability insurance is involved. The individual is entitled to Medicare. Who pays first or second?

Answer 73

No fault or liability insurance for accident or other situation related health care services claimed or released/WC or no-fault where ongoing responsibility for medical is reported. Medicare does not make a payment.

Question 74

For ongoing responsibility for medicals, Medicare DOES or DOES NOT make a payment until ORM funds are exhausted.

Answer 74

Does not

Question 75

Patient is 65 or older, or is disable and covered by Medicare or COBRA. The individual is entitled to Medicare. Who pays first or second?

Answer 75

Medicare pays first, COBRA pays second

Question 76

Health coverage sponsored by an employer or employee organization, such as a union, for a group of employees, and possibly for dependents and retirees as well

Answer 76

Group health plan

Question 77

The term group health plan includes:
____-insured plans
Plans of ____ entities (federal, state, and local)
Employee organization, such as ____ plans
Employee health and ____ funds
Other employee organizations

Answer 77

Self-insured
Government
Union
Welfare

Question 78

True or False:

The term group health plans does not include “employee-pay-all” plans which receive no financial contribution from the employer

Answer 78

False; does include “employee-pay-all” plans

Question 79

The term group health plan DOES or DOES NOT include self-employed persons

Answer 79

Does not

Question 80

Retiree health plans include individuals ____ years or older and has an employer retirement plan

Answer 80

65

Question 81

Patient is 65 years or older and has an employer retirement plans. Who pays first and second?

Answer 81

Medicare pays first, retiree coverage pays second

Question 82

Disability and employer group health plan includes an individual who is disables and is covered by a group health plan through his or her current employment (or through a family member’s current employment) AND the employer has ____ employees or more (or at least one employer is a multi-employer group that employs 100 or more individuals). What pays first and second.

Answer 82

GHP pays first, Medicare pays second

Question 83

Individual is 65 or older, is covered by a group health plan through current employment or spouse’s employment AND the employer has less than 20 employees. Who pays first and second?

Answer 83

Medicare pays first, GHP pays second

Question 84

Patient is 65 or older, is covered by a group health plan through current employment or spouse’s current employment AND the employer has 20 or more employees (or at least one employer is a multi-employer group that employs 20 or more individuals). Who pays first and second?

Answer 84

GHP pays first, Medicare pays second

Question 85

Provides continuing coverage of group health benefits to employees and their families upon the occurrence of certain qualifying events where such coverage would otherwise be terminated

Answer 85

COBRA

Question 86

Individual has end stage renal disease, is covered by COBRA, and is in the first 30 months of eligibility or entitlement to Medicare. Who pays first and second?

Answer 86

COBRA pays first, Medicare pays second during 30-month coordination period for ESRD

Question 87

Individual is 65 years or older and covered by Medicare and COBRA. Who pays first and second?

Answer 87

Medicare pays first, COBRA pays second

Question 88

Individual is disabled and covered by Medicare and COBRA

Answer 88

Medicare pays first, COBRA pays second

Question 89

Individual has end stage renal disease, is covered by a group health plan, and is in the first 30 months of eligibility or entitlement to Medicare. Who pays first or second?

Answer 89

GHP pays first, Medicare pays second during 30-month coordination period for ESRD

Question 90

Individual has end stage renal disease, is covered by COBRA, and is in the first 30 months of eligibility or entitlement to Medicare? Who pays first and second?

Answer 90

COBRA pays first, Medicare pays secondary during 30-month coordination period for ESRD

Question 91

Individual is entitled to Medicare and was in an accident or other situation where no-fault or liability insurance is involved. Who pays first or second?

Answer 91

No-fault liability or insurance pays first for accident or other situation related health care services claimed or released, Medicare pays second

Question 92

Medicare generally WILL or WILL NOT pay for an injury or illness/disease covered by workers comp

Answer 92

Will not

Question 93

When can a workers comp claim be filed with Medicare?

Answer 93

If all or part of a claim is denied by workers comp on the grounds that it is not covered by workers comp

Question 94

True or False:

Medicare won’t pay a claim that relates to a medical service or product covered by Medicare even if the claim is not covered by workers comp

Answer 94

False; may pay a claim that relates to a medical service or product covered by Medicare if the claim is not covered by workers comp

Question 95

Prior to settling a workers comp case, what should the parties to the settlement consider in relation to Medicare?

Answer 95

Medicare’s interest related to future medical services and whether the settlement is to include a workers comp Medicare set-aside agreement

Question 96

Individual is entitled to Medicare and is covered under workers comp because of a job-related illness or injury. Who pays first and second?

Answer 96

Works comp pay first for health care items or services related to a job-related illness or injury claim

Question 97

True or False:

Veterans entitled to Medicare may choose one of the programs to be responsible for payment of services covered by both programs

Answer 97

True

Question 98

Veterans entitled to Medicare may choose one of the programs to be responsible for payment of services covered by both programs. If the veteran elects Medicare coverage, is it necessary to submit a claim to VA before submitting the claim to Medicare?

Answer 98

It is not necessary to submit a claim to the VA for denial before submitting the claim to Medicare

Question 99

Can veterans choose to submit claims to both Medicare and the VA for the same dates and types of treatment?

Answer 99

No

Question 100

If a veteran elects Medicare coverage, a claim SHOULD or SHOULD NOT be submitted to the VA for the Medicare deductible or co-insurance

Answer 100

Should not

Question 101

When there is evidence that the no-fault insurer, liability insurer, or workers comp plan will not pay promptly, what type of payment may Medicare make?

Answer 101

A conditional payment

Question 102

A payment Medicare makes for services another payer may be responsible for

Answer 102

A conditional payment

Question 103

Why would Medicare make a conditional payment for a service that another payer may be responsible for?

Answer 103

So the beneficiary doesn’t have to use his/her own money to pay the bill

Question 104

Medicare may make a conditional payment for services another payer may be responsible for so the beneficiary doesn’t have to use his/her own money to pay the bill. Why is the payment called “conditional”?

Answer 104

Because it must be repaid to Medicare when a settlement, judgment, award, or other payment is made

Question 105

When a beneficiary has been paid by a primary plan, the amount a physician or other supplier who accepts the assignment may collect for Medicare covered services from the beneficiary is limited to what 2 things?

Answer 105

1) The amount paid or payable by the primary plan to the beneficiary (if this amount exceeds the amount that would be payable to Medicare as a primary payer, without regard to deductible or coinsurance, the physician or other supplier may retain the primary payment in full without violating the conditions of the assignment)
2) If the primary payment is less than the applicable Medicare deductible and coinsurance amounts, the difference between the fee schedule amount (or the amount the physician is obligated to accept as payment in full, if less) and the sum of the primary plan’s payment and the Medicare secondary payment

Question 106

When the primary insurer pays less than actual charges (e.g., under the terms of a preferred provider agreement) and less than the amount of the provider is obligated to accept as payment in full, what amount does Medicare use in its payment calculation?

Answer 106

The amount the provider is obligated to accept as payment is full

Question 107

When the primary insurer pays less than actual charges (e.g., under the terms of a preferred provider agreement) and less than the amount the provider is obligated to accept as payment in full, Medicare uses the amount the provider is obligated to accept as payment in full in its payment calculation. In such cases, the provider reports a value code ____ and the amount it is obligated to accept as payment in full. This amount is considered to be the provider’s charges

Answer 107

44

Question 108

The Benefits Coordination and Recovery Center consolidates that activities that support the identification, collection, management, and reporting of other ____ ____ ____ for Medicare beneficiaries.

Answer 108

Primary insurance coverage

Question 109

The Benefits Coordination and Recovery Center collects and supplies information on supplemental ____ ____ coverage

Answer 109

Prescription drug

Question 110

The Benefits Coordination and Recovery Center updates the ____ system with other insurance information

Answer 110

Medicare

Question 111

The Benefits Coordination and Recovery Center does not process ____ or answer ____-specific questions

Answer 111

Claims

Claim-specific

Question 112

The Benefits Coordination and Recovery Center uses multiple data collection activities to detect and identify other insurance coverage, such as:
\_\_\_\_ Enrollment Questionnaire (IEQ)
\_\_\_\_ Claims Investigation
IRS/SSA/CMS \_\_\_\_ Match
Data \_\_\_\_ Agreements
\_\_\_\_-Reports
Mandatory \_\_\_\_ Reporting

Answer 112

Initial
Secondary
Data
Sharing
Self
Insurer

Question 113

An ____ ____ ____ is typically sent to individuals approximately 3 months before they become entitled to Medicare

Answer 113

Initial Enrollment Questionnaire

Question 114

An Initial Enrollment Questionnaire is typically send to individuals approximately ____ months before they become entitled to Medicare

Answer 114

3

Question 115

What information does the Initial Enrollment Questionnaire contain?

Answer 115

Detail about how to complete the IEQ online

Question 116

The Initial Enrollment Questionnaire includes a serious of questions that solicits information about what?

Answer 116

Other insurance the person may have that is primary to Medicare

Question 117

The Benefits Coordination and Recovery Center uses the answers on the Initial Enrollment Questionnaire to help set up the beneficiary’s ____ and to add any new MSP ____ to Medicare’s records

Answer 117

File

Occurrences

Question 118

Providers of service may identify a payer they believe to be primary to Medicare. When this occurs, what should the provider do?

Answer 118

Bill the other insurance

Question 119

Providers of service may identify a payer to be primary to Medicare. When this occurs, the provider will bill the other insurance. After the other insurance processes the claim, what should the provider do?

Answer 119

Submit the claim to Medicare for consideration of any balance

Question 120

The Benefits Coordination and Recovery Center is alerted to the existence of other ____ and will ____ to confirm that it is truly primary to Medicare

Answer 120

Insurance

Investigate

Question 121

An electronic data match is performed by the Benefits Coordination and Recovery Center between which 3 organizations?

Answer 121

IRS, SSA, and CMS

Question 122

An electronic data match is performed by the BCRC between the IRS, SSA, and CMS. This data match identifies what?

Answer 122

Persons that have had earnings in a given tax year

Question 123

An electronic data match is performed by the BCRC between the IRS, SSA, and CMS. This data match identifies persons that have had earnings in a given tax year. If a Medicare beneficiary and/or spouse of a beneficiary has had earnings, what does this signify?

Answer 123

This signifies employment, which means it is possible they also had group health plan insurance coverage

Question 124

If a data match identifies persons that have had earnings, which signifies employment and possible group health plan insurance coverage, what is done?

Answer 124

A questionnaire is then sent to the employer inquiring about possible coverage that is primary to Medicare

Question 125

If a data match identifies persons that have had earnings, which signifies employment and possible group health plan insurance coverage, a questionnaire is then sent to the employer inquiring about possible coverage that is primary to Medicare. What happens if coverage exists or existed?

Answer 125

Date of coverage are obtained, as well as the name and address of the insurer

Question 126

True or False:

Records obtained through the IRS/SSA/CMS process are generally unreliable

Answer 126

False; are generally reliable

Question 127

Employers, insurers, attorneys, and beneficiaries will ____-____ group health plan and non-group health plan occurrences through telephone calls or written correspondence to the BCRC

Answer 127

Self-report

Question 128

What does the BCRC representative do if an MSP occurrence is self-reported by telephone?

Answer 128

BCRC reps will review existing records and make any additions or changes based upon information received during the call

Question 129

What happens if written correspondence that self-reports an MSP occurrence is received, but the information is incomplete or inconsistent with existing records?

Answer 129

Development letters are sent

Question 130

Development letters are sent in which circumstance?

Answer 130

When there is a need to gather additional information about the matter being addressed

Question 131

File proper and timely claims with the appropriate primary payer. Not filing proper and timely claims with the appropriate primary payer may result in ____ ____ by that payer

Answer 131

Claim denial

Question 132

Federal law allows Medicare to recover what type of payments?

Answer 132

Improper payments

Question 133

True or False:

Medicare requires the return of any payment made in error as the primary payer

Answer 133

True

Question 134

Medicare recovers mistaken payments in which situations?

Answer 134

MSP GHP situtations

Question 135

Medicare can also ____ providers, physicians, and other suppliers for knowingly, willfully, and repeatedly giving inaccurate health insurance information

Answer 135

Fine