Some patients with Medicare also have other health insurance coverage through an employer or spouse’s employer, or on a case by case basis for accidents, injuries, or illnesses covered by workers compensation, liability, or no-fault Insurance. In those cases, Medicare serves as the secondary payer (MSP) and should be billed only after providers bill the other insurer first.
In some situations, though, Medicare may deny a claim indicating that Medicare is the secondary payer when, in fact, you have no primary payer on file. When this is the case, what should you do?
Confirm Medicare is Primary
First, confirm that there is not a primary payer. Medicare law and regulations require all entities that bill Medicare to decide whether Medicare is the primary payer before submitting a claim. There are many different factors when considering whether another payer is primary or secondary. Page 16 of Chapter 3 of the Medicare Secondary Payer Manual provides guidance on finding other primary payers. If you do determine the patient has another payer that’s primary, bill them first. After receiving the primary payer remittance advice, you can then bill Medicare as the secondary payer.
Remember that just because a patient has Medicare as a primary payer in one situation, that doesn’t mean Medicare is primary in every situation, particularly when it comes to injuries or illnesses related to workers compensation, liability, or no-fault Insurance. If you see a beneficiary for multiple services, bill each service to the proper primary payer.
File an Appeal
Next, determine if the diagnosis on the current claim is the same, or within the same family, as the diagnosis codes on a previous accident, injury, or illness record. Even if the service is not related to the previous encounter, Medicare may inappropriately deny your claim because the diagnosis codes on the claim and the MSP record are the same, or within the same family.
In this case, you should appeal the inappropriately denied claim with your Medicare Administrative Contractor and provide an explanation or a reason code to show that the services aren’t related to the accident, injury, or illness on record.
Don’t Penalize the Patient
Finally, don’t resolve the issue by instructing Medicare beneficiaries to delete open MSP records with the Benefits Coordination and Recovery Center (BCRC), even if those open records are causing problems with the current claim. In many situations, the open record may be active and if it’s deleted, future claims related to the earlier accident, injury, or illness may not be paid.
As well, don’t bill the Medicare beneficiary for the inappropriately denied claims or refer the claims to a collection agency. The claim issue should be resolved with your MAC by following an appeal.
For more information about billing Medicare as a secondary payer, review the following resources:
- Billing for Services when Medicare is a Secondary Payer — MLN Matters Number: SE21002
- Medicare Secondary Payer webpage
- Medicare & Other Health Benefits: Your Guide to Who Pays First
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