Billing & Coding - Section 3: Medicare Secondary Payer Flashcards
When Medicare began in 1966, it was the primary payer for all claims, except for what?
Workers Comp
Federal Black Lung benefits
Veteran’s Administration (VA)
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
1980
In 1980, Congress passed legislation that made Medicare the secondary payer to certain primary plans. Why was this done?
To shift costs from Medicare to the appropriate private sources of payment
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)
Medicare Seconday Payer
How have the MSP provisions protected Medicare trust funds?
By ensuring that Medicare doesn’t pay for items and services that certain health insurance or coverage is primarily responsible for paying
The Centers for Medicare and Medicaid Services (CMS) enforcement of MSP provisions saved the Medicare Program approximately $____ in Fiscal Year 2018
$8.5 billion
Billing a primary plan before Medicare may provide you with ____ reimbursement rates
Better
Coordinated health coverage may ____ the payment process and ____ administrative costs
Expedite
Reduce
Filing claim correctly the first time prevents future Medicare ____ efforts on claims
Recovery
The MSP provisions apply to situations when Medicare is not the beneficiary’s ____ health insurance coverage
Primary
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
False; primary payer
Primary payers are those that have the ____ responsibility for paying a claim.
Primary
Does Medicare remain the primary payer for beneficiaries who are not covered by other types of heatlh insurance or coverage?
Yes
Primary payers must pay a claim ____
First
Medicare pays ____ for beneficiaries in the absence of other primary insurance or coverage
First
True or False:
Medicare never pays first when the beneficiary has other insurance coverage
False; may pay first
____ ____ ____ help ensure Medicare payments are made in the proper order by being knowledgeable of and participating in Coordination of Benefits processes
Responsible Reporting Entities
What is the purpose of Coordination of Benefits?
To identify the other insurance benefits available to a Medicare beneficiary, and to coordinate the payment process to prevent mistaken payment of Medicare benefits
Are Required Report Entities required to report information about certain persons they insure to the Benefits Coordination and Recovery Center?
Yes
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?
Check to see if any of these persons also have Medicare coverage
If the BCRC determines that a person has Medicare coverage, what will happen?
The employe’s insurance will be primary to Medicare and an MSP occurence will be created
For Medicare programs to work effectively, ____have a significant responsibility for the collection and maintenance of patient information.
Providers
Providers must ask beneficiaries questions to secure ____ and ____ information
Employment and insurance
Providers have a responsibility to indentify payers other than Medicare so that incorrect ____ and ____ are minimized
Billing and overpayments
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
Medicare
True or False:
Failure to maintain a system of identifying other payers is viewed as a violation of the provider agreement with Medicare
True
The patient must respond to MSP claims development letters in timely manner to ensure what happens?
Correct payment of their Medicare claims
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
Employment
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?
Their doctor, other providers, and BCRC (benefits coordination and recovery center)
A patient should contact the ____ if they, or an attorney on their behalf, takes legal action for a medical claim
Benefits coordination and recovery center
A patient should contact the BCRC if they are involved in a ____ accident
Automobile
A patient should contact the BCRC if they are involved in a ____ ____ case
Workers comp
Employers must ensure that their plans identify what in relation to MSP?
Those individuals to whom the MSP requirement applies
Employers must ensure that their plans provide for proper ____ payments where by law Medicare is the secondary payer
Primary
Employers must ensure that they do not discriminate against employees and employees’ spouses within what 3 groups?
1) Age 65 or older
2) Who suffer from permanent kidney failure
3) Disabled Medicare beneficiaries for whom Medicare is secondary payer
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
Primary or secondary
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
Inpatient admission or outpatient encounter
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
Prior
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?
By asking Medicare beneficiaries about other coverage
Are RHCs considered Part A or Part B providers?
RHCs and FQHCs are Medicare Part B providers
If a patient presents at the RHC/FQHC with Medicare Part A ONLY, they are considered “____-____” in the RHC or FQHC
Self-pay
Which Medicare part are physician’s services covered by?
Part B
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
Part B
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
Part B
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
Part B
Which Medicare part is the below covered by?
Outpatient physical therapy services, occupational therapy services, and speech-language pathology services
Part B
Which Medicare part is the below covered by?
Rural health clinic services and federally qualified health center services
Part B
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
MSP
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
Legal
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
MSP
Electronic
Part B providers (physicians, practitioners, and suppliers) gather accurate MSP data to determine if Medicare is the primary payer through what means?
Asking Medicare beneficiaries, or their representatives, for MSP information
Part B providers (physicians, practitioners, and suppliers) bill the primary payer ____ billing Medicare
Before
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
EOB
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
Admission
Part A providers (hospitals) bill the ____ payer before billing Medicare
Primary
Part A providers (hospitals) submit any MSP information on your ____ claim using proper payment information, value codes, condition and occurrence codes, etc.
Medicare
True or False:
It is required to provide the MSP Questionnaire to Medicare beneficiaries
False; it is required to ask MSP questions at each encounter but you do not have to use the questionnaire
Why should the CMS questionnaire be used?
To determine the primary payer of the beneficiary’s claims
The CMS questionnaire consists of ____ part and lists questions to ask Medicare beneficiaries
6
MSP questions must be asked at which frequency?
At each visit/encounter
What is the exception to asking MSP questions at each visit/encounter?
The exception of policies regarding hospital lab services, recurring patient services, and Medicare+Choice organization members
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 ____
Sequence
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)
True
There are programs under which payment for services is usually excluded from both primary and secondary Medicare payments. What are those programs?
Veteran’s Administration
Federal Black Lung
Medicare does not pay for the same services covered by ____ benefits
Veteran’s Administration
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
Black lung
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?
Medicare first, GHP second
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?
GHP first, Medicare second
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?
Medicare first, retiree coverage second
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?
Medicare first, GHP second
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?
GHP first, Medicare secondary
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?
WC for health care items or services related to job-related illness or injury pays first, Medicare pays second
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?
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.
For ongoing responsibility for medicals, Medicare DOES or DOES NOT make a payment until ORM funds are exhausted.
Does not
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?
Medicare pays first, COBRA pays second
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
Group health plan
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
Self-insured
Government
Union
Welfare
True or False:
The term group health plans does not include “employee-pay-all” plans which receive no financial contribution from the employer
False; does include “employee-pay-all” plans
The term group health plan DOES or DOES NOT include self-employed persons
Does not
Retiree health plans include individuals ____ years or older and has an employer retirement plan
65
Patient is 65 years or older and has an employer retirement plans. Who pays first and second?
Medicare pays first, retiree coverage pays second
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.
GHP pays first, Medicare pays second
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?
Medicare pays first, GHP pays second
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?
GHP pays first, Medicare pays second
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
COBRA
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?
COBRA pays first, Medicare pays second during 30-month coordination period for ESRD
Individual is 65 years or older and covered by Medicare and COBRA. Who pays first and second?
Medicare pays first, COBRA pays second
Individual is disabled and covered by Medicare and COBRA
Medicare pays first, COBRA pays second
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?
GHP pays first, Medicare pays second during 30-month coordination period for ESRD
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?
COBRA pays first, Medicare pays secondary during 30-month coordination period for ESRD
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?
No-fault liability or insurance pays first for accident or other situation related health care services claimed or released, Medicare pays second
Medicare generally WILL or WILL NOT pay for an injury or illness/disease covered by workers comp
Will not
When can a workers comp claim be filed with Medicare?
If all or part of a claim is denied by workers comp on the grounds that it is not covered by workers comp
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
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
Prior to settling a workers comp case, what should the parties to the settlement consider in relation to Medicare?
Medicare’s interest related to future medical services and whether the settlement is to include a workers comp Medicare set-aside agreement
Individual is entitled to Medicare and is covered under workers comp because of a job-related illness or injury. Who pays first and second?
Works comp pay first for health care items or services related to a job-related illness or injury claim
True or False:
Veterans entitled to Medicare may choose one of the programs to be responsible for payment of services covered by both programs
True
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?
It is not necessary to submit a claim to the VA for denial before submitting the claim to Medicare
Can veterans choose to submit claims to both Medicare and the VA for the same dates and types of treatment?
No
If a veteran elects Medicare coverage, a claim SHOULD or SHOULD NOT be submitted to the VA for the Medicare deductible or co-insurance
Should not
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?
A conditional payment
A payment Medicare makes for services another payer may be responsible for
A conditional payment
Why would Medicare make a conditional payment for a service that another payer may be responsible for?
So the beneficiary doesn’t have to use his/her own money to pay the bill
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”?
Because it must be repaid to Medicare when a settlement, judgment, award, or other payment is made
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?
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
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?
The amount the provider is obligated to accept as payment is full
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
44
The Benefits Coordination and Recovery Center consolidates that activities that support the identification, collection, management, and reporting of other ____ ____ ____ for Medicare beneficiaries.
Primary insurance coverage
The Benefits Coordination and Recovery Center collects and supplies information on supplemental ____ ____ coverage
Prescription drug
The Benefits Coordination and Recovery Center updates the ____ system with other insurance information
Medicare
The Benefits Coordination and Recovery Center does not process ____ or answer ____-specific questions
Claims
Claim-specific
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
Initial Secondary Data Sharing Self Insurer
An ____ ____ ____ is typically sent to individuals approximately 3 months before they become entitled to Medicare
Initial Enrollment Questionnaire
An Initial Enrollment Questionnaire is typically send to individuals approximately ____ months before they become entitled to Medicare
3
What information does the Initial Enrollment Questionnaire contain?
Detail about how to complete the IEQ online
The Initial Enrollment Questionnaire includes a serious of questions that solicits information about what?
Other insurance the person may have that is primary to Medicare
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
File
Occurrences
Providers of service may identify a payer they believe to be primary to Medicare. When this occurs, what should the provider do?
Bill the other insurance
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?
Submit the claim to Medicare for consideration of any balance
The Benefits Coordination and Recovery Center is alerted to the existence of other ____ and will ____ to confirm that it is truly primary to Medicare
Insurance
Investigate
An electronic data match is performed by the Benefits Coordination and Recovery Center between which 3 organizations?
IRS, SSA, and CMS
An electronic data match is performed by the BCRC between the IRS, SSA, and CMS. This data match identifies what?
Persons that have had earnings in a given tax year
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?
This signifies employment, which means it is possible they also had group health plan insurance coverage
If a data match identifies persons that have had earnings, which signifies employment and possible group health plan insurance coverage, what is done?
A questionnaire is then sent to the employer inquiring about possible coverage that is primary to Medicare
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?
Date of coverage are obtained, as well as the name and address of the insurer
True or False:
Records obtained through the IRS/SSA/CMS process are generally unreliable
False; are generally reliable
Employers, insurers, attorneys, and beneficiaries will ____-____ group health plan and non-group health plan occurrences through telephone calls or written correspondence to the BCRC
Self-report
What does the BCRC representative do if an MSP occurrence is self-reported by telephone?
BCRC reps will review existing records and make any additions or changes based upon information received during the call
What happens if written correspondence that self-reports an MSP occurrence is received, but the information is incomplete or inconsistent with existing records?
Development letters are sent
Development letters are sent in which circumstance?
When there is a need to gather additional information about the matter being addressed
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
Claim denial
Federal law allows Medicare to recover what type of payments?
Improper payments
True or False:
Medicare requires the return of any payment made in error as the primary payer
True
Medicare recovers mistaken payments in which situations?
MSP GHP situtations
Medicare can also ____ providers, physicians, and other suppliers for knowingly, willfully, and repeatedly giving inaccurate health insurance information
Fine
