Some patients have more than one health insurance plan. A physician’s claim for reimbursement is processed twice: first by the primary insurer, then by the secondary insurer to pay some or all remaining expenses. While Medicare is often the primary insurer, that is not always the case, so coordination of benefits is critical.
Essential Steps for Medicare Billing
The Medicare Learning Network provides the following tips1 that retina practices should follow to ensure problem-free processing and correct and prompt payments:
- Collect full beneficiary health insurance information upon each office visit, outpatient visit, and hospital admission.
- Determine the primary payer before submission of a claim and bill the proper responsible payer(s) for related services.
- Check Medicare eligibility to identify accident or injury diagnosis codes for L, NF, or WC MSP periods.
- For multiple services, bill each responsible payer(s) separately.
- If a beneficiary is treated for accident-related services as well as services that are not related to the accident, don’t submit both sets of services on the same claim to Medicare. Send separate claims to Medicare: a claim for services related to the accident and a second claim for services unrelated to the accident.
- Always use specific diagnosis codes related to the accident or injury.
According to the Centers for Medicare and Medicaid Services (CMS), all entities that bill Medicare for services or items given to Medicare beneficiaries must determine which entity is the primary payer before submitting a claim to Medicare.1
Q. How is the primary payer determined?
A. When a Medicare beneficiary has another health insurance plan, the coordination of benefits rules determine which one pays first.2,3 Medicare is the secondary payer (MSP) when the beneficiary:
- is age 65 years or older and covered by a group health plan (GHP) through current employment (including self employment) or a spouse’s current employment, and the employer has 20 or more employees;4
- is disabled and is covered by a GHP through an employer with more than 100 employees;4
- has end-stage renal disease (ESRD) and is covered by a GHP through the Consolidated Omnibus Budget Reconciliation Act (COBRA) or a retirement plan for a coordination period of 30 months;5
- has an accident covered by no-fault or liability insurance;6 or
- receives care covered by Workers’ Compensation Insurance.6
Medicare is the primary payer if the beneficiary:
- is age 65 years or older and covered by a GHP through their own or a spouse’s employment, and the employer has fewer than 20 employees;2
- is age 65 years or older and covered by both COBRA and Medicare;3,4,7
- is disabled and covered by both COBRA and Medicare;7 or
- is age 65 years or older and covered by an employer retirement plan.
CMS notes that federal law (specifically section 1862(b) of the Social Security Act) takes precedence over state laws and private contracts. “Even if an entity believes that it is the secondary payer to Medicare due to state law or the contents of its insurance policy, the MSP provisions would apply when billing for services,” note CMS guidelines.2
Q. If Medicare is determined to be the secondary payer, how should the practice proceed?
A. If another insurer is the primary payer, bill them first. After receiving the primary payer’s remittance advice, bill Medicare as the secondary payer.2 At that point, the beneficiary’s financial responsibility would be determined by the Medicare Administrative Contractor (MAC). Medicare might not pay the entire outstanding amount, and an individual may still have out-of-pocket expenses.
When Medicare is deemed to be the secondary payer, Medicare Part B providers (eg, physicians, ambulatory surgery centers (ASCs), and suppliers) are responsible for:
- Collecting relevant MSP information such as GHP coverage;
- Claims submission with an Explanation of Benefits (EOB); and
- Inquiring with the beneficiary at the time of the visit if he/she is taking legal action in conjunction with the services performed.8
Q. What if the practice can’t determine the primary and secondary payers?
A. CMS established the Benefits Coordination and Recovery Center (BCRC) to conduct MSP investigations. While the BCRC does not process or pay claims, it provides information related to all MSP-related inquiries to beneficiaries, attorneys, employers, insurers, providers, and suppliers seeking general MSP information. If a provider submits a claim on behalf of a beneficiary and there is uncertainty about whether Medicare or an insurer should be designated as the primary payer, the BCRC will investigate the claim.
According to CMS, “The goal of MSP information gathering and investigation is to identify MSP situations quickly and accurately, thus ensuring correct primary and secondary payments by the responsible party.”8 The BCRC can be reached at 1-855-798-2627. RP
References
1. Centers for Medicare and Medicaid Services Medicare Learning Network. Billing for services when Medicare is a secondary payer. February 23, 2021. Accessed October 5, 2024. https://www.cms.gov/files/document/se21002.pdf
2. Centers for Medicare and Medicaid Services. Medicare secondary payer. September 10, 2024. Accessed October 5, 2024. https://www.cms.gov/medicare/coordination-benefits-recovery/overview/secondary-payer
3. Centers for Medicare and Medicaid Services. Coordination of benefits and recovery overview. September 10, 2024. Accessed October 5, 2024. https://www.cms.gov/medicare/coordination-benefits-recovery/overview
4. Social Security Administration. Medicare information. Accessed October 5, 2024. https://www.ssa.gov/disabilityresearch/wi/medicare.htm
5. Centers for Medicare and Medicaid Services. End-stage renal disease (ESRD). September 10, 2024. Accessed October 5, 2024. https://www.cms.gov/medicare/coordination-benefits-recovery/overview/end-stage-renal-disease-esrd
6. Centers for Medicare and Medicaid Services. Liability, no-fault and workers’ compensation reporting. September 10, 2024. Accessed October 5, 2024. https://www.cms.gov/medicare/coordination-benefits-recovery/beneficiary-services/liability-no-fault-workers-compensation-reporting
7. Centers for Medicare and Medicaid Services. COBRA continuation coverage questions and answers. September 10, 2024. Accessed October 5, 2024. https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/cobra_qna
8. Centers for Medicare and Medicaid Services. Provider services. September 10, 2024. Accessed October 5, 2024. https://www.cms.gov/medicare/coordination-benefits-recovery/provider-services
