Title: Primary/Secondary Payor Source

Transcription

1 Effective Date: 11/00; Rev. 2/02, 10/04, 11/06; 10/08, 8/11 POLICY: All agencies/departments providing Home Health Care Services (as defined below) shall follow appropriate enrollment and evaluation procedures to establish primary and secondary funding sources. Billing and oversight will be exercised to avoid duplicate billing to more than one payor. SCOPE: IHS system wide. All IHS and affiliate facilities providing Home Health Care Services, defined to include Medicare certified home health, home medical equipment, infusion, private duty, hospice, and emergency response services. BACKGROUND: The purpose of this policy is to establish a system to prevent duplicate billing for services. Although duplicate billing can occur due to simple error, knowing, duplicate billing which is sometimes evidenced by systematic or repeated double billing can create liability under criminal, civil, or administrative law, particularly if any overpayment is not promptly refunded. PROCEDURES: 1. Definitions. 1.1 Duplicate billing occurs when the bill is submitted to more than one payor with the purpose of obtaining primary payment. 1.2 Primary payor is the insurer that has the initial obligation to cover medical expenses for the beneficiary. Most insurers have adopted a Coordination of Benefits program to assure appropriate coverage/payment for individuals with multiple funding sources. Under Medicare law, Medicare payment may not be made for any items or services to the extent payment has been made or can reasonably be expected to be made promptly (usually 120 days) by another payor. (See Attachment A for guidance regarding coverage by other payors.) 2. Home health staff will determine if Medicare is the primary or secondary payor at the time of admission. Page 1 of 6 8/11

2 3. Examples of when Medicare is the secondary payor are as follows: 3.1 A beneficiary s injuries are related to an automobile accident or other type of accident where another party is at fault, or when the accident is the beneficiary s fault and his or her own auto insurance assumes responsibility; 3.2 An Employer Group Health Plan (EGHP) covers the employee entitled to Medicare on the basis of end stage renal disease; 3.3 An EGHP with 20 or more employees covers the employee, age 65 or older, or his or her spouse, age 65 or older; 3.4 A Large Group Health Plan (LGHP) with 100 or more employees covers the employee or his or her spouse entitled to Medicare disability; 3.5 The requested care arises out of a work-related illness or injury that is covered under workers compensation. 4. If Medicare acts as the primary payor under the circumstances set forth in Section 3, the Medicare payment is subject to recovery by the Medicare Program. If uncertainty exists whether Medicare s liability for payment will be primary or secondary, Medicare will usually make a conditional payment, to be recovered later if Medicare s liability turns out to be secondary. 5. If Medicare is the secondary payor, the primary payors should be billed before billing Medicare, except when the primary payor is a liability insurer. In such case, Medicare will make a conditional payment and request a refund on any overpayment after the liability insurer has paid. 6. If Medicare is the secondary payor and the agency/department receives payment for the same services from Medicare and the primary payor due to incomplete information from the client, the agency/department must reimburse Medicare any overpaid amount within 60 days. 7. If the agency/department bills a payor primary to Medicare and receives payment that is reduced because the agency/department failed to file the proper claim, the agency/department should: 7.1 Bill Medicare no more than would have been payable as secondary payment if the primary insurer s payment had been based on a proper claim. 7.2 Charge the beneficiary only what the agency/department would have been entitled to charge if it had filed a proper claim and received payment based on such a claim. However, the beneficiary can be charged an amount equal to any third-party payor payment reduction attributable to failure to file a proper claim if the agency/department can show that: Page 2 of 6 8/11

3 7.2.1 It failed to file a proper claim solely because the beneficiary, for reason other than mental or physical incapacity, failed to give the agency/department accurate and necessary information The beneficiary, who was responsible for filing a proper claim, failed to do so for any reason other than mental or physical incapacity. /s/ William B. Leaver William B. Leaver IHS President REFERENCES: OIG Compliance Program Guidance for Home Health Agencies, August 1998; 63 FR 42410, Aug. 7, Page 3 of 6 8/11

4 ATTACHMENT A Coverage Primary over Medicare Workers Compensation (enacted ) Medicare has no liability for work-related injuries or illness covered by workers compensation until the workers compensation benefits run out. However, Medicare can pay conditionally (i.e., pay the claim as if Medicare was primary) if the workers compensation case is litigated and the health care providers do not wish to wait for the settlement. Medicare pays covered services if a beneficiary s injury is not work-related or if the beneficiary is ineligible for workers compensation benefits. Medicare Secondary Payer Manual, CMS Pub , Ch. 1, 10 (rev. 2005). Veterans Administration The Veterans Administration (VA) may authorize private physicians and other suppliers to provide services at federal expense to certain veterans with service connected or non-service connected disabilities. An authorization issued by the VA generally binds the VA to pay for the services provided, and no payments are made under Medicare. Medicare can pay for services where neither the physician/supplier nor the beneficiary has claimed benefits from the VA. Medicare may also pay for services that the VA does not cover. Medicare Benefits Policy Manual, CMS Pub , Ch. 16, 50 (rev. 2007). Black Lung Disease (enacted ) The Federal Coal Mine Act established the Black Lung Program which was set up to pay medical benefits to coal miners with conditions related to black lung. Medicare will not pay for services covered by the Federal Black Lung Program. Medicare Secondary Payer Manual, CMS Pub , Ch. 1, 10 (rev. 2005). Injuries Covered by Auto or Liability Insurance (enacted ) For injuries involving auto or liability insurance, Medicare is the secondary payor. Auto insurance is the beneficiary s own insurance that they carry on their own automobile or the automobile in which they are a passenger. Liability insurance is the insurance that provides payment when responsibility is established for injury or illness. Medicare will pay claims conditionally for all auto or liability insurer claims; that is, Medicare will pay first and request a refund on any overpayment after the auto or liability insurer has paid. If the Agency or facility becomes aware that auto or liability insurance is involved, request a conditional payment. Medicare Secondary Payer Manual, CMS Pub , Ch. 2, 40 (rev. 2006). Page 4 of 6 8/11

5 End-Stage Renal Disease (enacted ) If an individual is entitled to Medicare because of end-stage renal disease (ESRD) and is covered by an Employer Group Health Plan (EGHP), the EGHP insurance is primary for the first 18 months. The EGHP is primary regardless of the number of employees in the group. (The EGHP was primary for 12 months. If your patient was diagnosed on or after February 1, 1990, the EGHP is primary for 18 months.) The Omnibus Budget Reconciliation Act of 1993 (OBRA 1993) resulted in additional changes in the coordination period for ESRD beneficiaries with dual entitlement. Medicare Secondary Payer Manual, CMS Pub , Ch. 2, 20 (rev. 2006). Tax Equity and Fiscal Responsibility Act (TEFRA) (enacted )* The TEFRA law affects employers with 20 or more full- or part-time employees. Under TEFRA, employers must offer their working employees, or the spouses of their employees, ages the same primary health care coverage as their younger employees. Medicare Secondary Payer Manual, CMS Pub , Ch. 1, 50 (rev. 2006). Deficit Reduction Act (DEFRA) (enacted )* The DEFRA law extended the TEFRA ruling to include employees spouses, ages regardless of the age of the employee. The spouse has the same choices as allowed in TEFRA. The employer must have 20 or more full- or part-time employees to be affected by this law. Deficit Reduction Act of 1984, Pub. L , July 18, Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)* The COBRA law extended the TEFRA and DEFRA laws even further by extending the working age for both employees and spouses beyond age 69. The employee and spouse, over age 65, have the same choices as in TEFRA and DEFRA. The 20 or more full- or part-time rule applies to this law. This provision of the law became effective on May 1, A second provision of this law allows private health care providers to pay VA hospitals for non-service related illnesses or injuries. (Services provided to disabled veterans are exempt.) This provision of the law was effective on October 1, 1986, and applies to both inpatient and outpatient services. Another COBRA provision requires employers to offer certain terminated employees and/or their families the opportunity to continue receiving the employer s health plan benefits (called an extension of benefits). Employers are not required to offer this extension of benefits to individuals who are eligible for Medicare. Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L , April 7, Omnibus Budget Reconciliation Act of 1986 (OBRA) (enacted )* The OBRA law affects employers with 100 or more full- or part-time employees. Under OBRA, employers must offer their employees or their spouses who are under age 65 and entitled to Medicare due to disability the same primary health care coverage as other employees. As of August 10, 1993, the employee must be actively working in order to Page 5 of 6 8/11

6 choose Medicare as a secondary payor. Omnibus Budget Reconciliation Act of 1986, Pub. L , Oct. 21, * Individuals are exempt from the TEFRA, DEFRA, COBRA and OBRA laws if they are not entitled to Medicare Part A. Employees affected by TEFRA, DEFRA, COBRA, or OBRA laws may choose Medicare as their primary insurer. If an individual chooses Medicare as primary, he or she is not eligible to continue on the employer s health care plan. If the employee selects a Medicare supplemental policy after being dropped from the employer s plan, Medicare is primary, the supplemental plan is secondary. Page 6 of 6 8/11