Medicare Secondary Payer Regulations as Applicable to Accident Claims

Transcription

1 Medicare Secondary Payer Regulations as Applicable to Accident Claims HFMA 18 th Annual Fall Conference Kansas City, Missouri October 22-24, 2014

2 Chad Powers, Esq. Vice President, General Counsel Medical Reimbursements of America, Inc Carothers Parkway Franklin, TN DISCLAIMER - This publication is designed to provide general information in regard to the subject matter covered. It is provided with the understanding that the publisher is not engaged in rendering legal or other professional services. Although prepared by individuals experienced in the medical reimbursement industry, this publication should not be utilized as a substitute for professional services in specific situations. Although the individuals who prepared the publication may be legal professionals individually, such individuals are not presenting the information covered herein as legal experts in the medical reimbursement industry. If legal advice or other assistance is required, the services of a professional should be sought.

3 Presentation Overview Accident-Injury Patient Accounts Medicare Secondary Payer Conclusion Q & A

4 Brief Overview of Medicare Secondary Payer

5 Brief Overview of MSP What is MSP? The MSP provisions protect the Medicare Trust Fund by ensuring Medicare does not pay for items and services when other insurance coverage is primarily responsible for paying. The MSP provisions apply to situations where Medicare is not the primary or first payer of claims. When does Medicare Pay First? Medicare pays first for beneficiaries in the absence of other primary insurance or coverage. Medicare may also pay first where the beneficiary has other insurance coverage, but a special condition also exists.

6 MSP For Accident-Injury

7 Medicare Secondary Payer: A Brief History

8 Medicare is always primary MSP Timeline C.F.R (c)(2) has rigid 120-day Promptly Period 2003 CMS issues the Final Rule, implementing the modern-day Promptly Period 1980 Medicare Act amended making Medicare secondary to most payers 1990 AHA v. Sullivan voids the rigid Promptly Period

9 Accident-Injury Patient Accounts

10 Types of Insurance Related to Accident Claims Med Pay (No-Fault) PIP (No-Fault) Workers Compensation Commercial Health Insurance Government Health Insurance Liability Insurance Under/Un-insured Motorist Coverage

11 No-Fault Insurance vs. Liability Insurance: A Brief Overview

12 No-Fault Insurance vs. Liability Insurance No-Fault Insurance: No-Fault Insurance (e.g. Med Pay or PIP) is first party coverage. Pays regardless of fault. Pays the cost of necessary medical care received as a result of an accident. The insurance company has a contractual obligation to pay for medical services provided to the covered person. Liability Insurance: May cover: medical expenses, lost wages, pain and suffering, and attorney s fees. If Patient is found at-fault or if fault cannot be determined, liability will not cover Patient s medical expenses. The insurance has a contractual obligation to compensate the alleged tortfeasor for any damages the alleged tortfeasor must pay to an injured party.

13 Medicare Secondary Payer: No-Fault COB and Condition Code 08

14 Medicare COB: No-Fault Insurance If services are covered under no-fault insurance, that insurance must be billed first. The question in each case involving accident-related medical expenses is whether no-fault benefits can be paid for these particular services. If so, the no-fault insurance is primary. If not, Medicare may be primary. Primary Medicare benefits cannot be paid merely because the beneficiary wants to save insurance benefits to pay for future services or for noncovered medical services or non-medical services. Since no-fault insurance benefits would be available in that situation, they must be used before Medicare can be billed.

15 Medicare Beneficiary s Responsibility RE: No-fault Insurance Must take whatever action is necessary to obtain payment; Medicare will not pay unless: Beneficiary has exhausted no-fault remedies, or; Beneficiary has filed a proper claim for no-fault insurance benefits but the intermediary or carrier determines that the no-fault insurer will not pay promptly; Medicare will not pay for services that would have been covered under no-fault if beneficiary had filed a proper claim. 42 C.F.R

16 Condition Code 08- Uncooperative/Unresponsive Patient Condition Code (CC) 08 is used when a beneficiary actively refuses to give other health information or is unable to give other health information. Use along with remarks to indicate refusal to supply other insurance information. Submit the claim as Medicare primary. CC 08 alerts the Benefit Coordination and Recovery Center (BCRC) to develop for other insurance information (including contacting the beneficiary). Note: This code CAN be used for non-response as well. Where CC 08 is reported the contractor rejects the claim. BCRC receives an automatic trigger from the common working file for claims filed with the CC 08 and developed with the beneficiary. Providers who use CMS Form-1450 or its electronic equivalent should report CC 08 ( beneficiary would not furnish information concerning other insurance coverage ) when a beneficiary refuses to answer or provide you with other payer information.

17 Medicare Secondary Payer: Liability COB

18 Promptly Rule Revisited Liability Insurance Promptly Definition: The insurer did not pay within 120 days of the earlier of the following: The date a general liability claim is filed with the insurer or a lien is filed against a potential liability settlement, OR The date of service (date of discharge, for inpatient services). For the liability situation, in the absence of evidence to the contrary, the date the general liability claim is filed against the liability insurance (including selfinsurance) is no later than the date that the record was posted on Medicare s CWF. Therefore, for the purposes of determining the promptly period, Medicare contractors consider the date the Liability record was created on Medicare s CWF to be the date the general liability claim was filed.

19 Medicare COB: Liability Insurance Liability insurance vs. No-Fault insurance. Following expiration of the promptly period, or if demonstrated that liability insurance will not pay during the promptly period, a provider may either: Bill Medicare for payment and withdraw all claims/liens against the liability insurance; OR Maintain all claims/liens against the liability insurance. NOTE: Medicare beneficiaries are not required to file a claim with a liability insurer or required to cooperate with a provider in filing such a claim, but they are required to cooperate in the filing of no-fault claims.

20 Medicare Secondary Payer: Conditional Payment

21 Conditional Medicare Payment General Rule: Medicare may not make payment on a MSP claim where payment has been made or can reasonably be expected to be made by GHPs, a WC law or plan, liability insurance (including self-insurance), or nofault insurance. HOWEVER...

22 Conditional Medicare Payment (Cont d) Medicare can make conditional payments for both Part A and Part B WC, or no-fault, or liability insurance (including self insurance) claims if: (i) payment has not been made or cannot be reasonably expected to be made by the WC, or no-fault, or liability insurance claims (including self insurance); AND (ii) the promptly period has expired. These payments are made on condition that the trust fund will be reimbursed if it is demonstrated that WC, no-fault, or liability insurance is (or was) responsible for making primary payment. 42 C.F.R to.53

23 Conditional Payment for No-Fault and WC Claims Conditional payments for claims for specific items and service may be paid by Medicare where the following conditions are met: There is information on the claim or information on Medicare s CWF that indicates the no-fault insurance or WC is involved for that specific item or service; There is/was no open GHP record on the Medicare CWF MSP file as of the date of service; There is information on the claim that indicates the physician, provider or other supplier sent the claim to the no-fault insurer or WC entity first; AND There is information on the claim that indicates the no-fault insurer or WC entity did not pay the claim during the promptly period.

24 Conditional Payment for Liability (incl. Self Insurance) Claims? Conditional payments for claims for specific items and service may be paid by Medicare where the following conditions are met: There is information on the claim or information on Medicare s CWF that indicates liability insurance (including self-insurance) is involved for that specific item or service; There is/was no open GHP record on the Medicare s CWF MSP file as of the date of service; There is information on the claim that indicates the physician, provider or other supplier sent the claim to the liability insurer (including the self-insurer) first, AND There is information on the claim that indicates the liability insurer (including the self insurer) did not make payment on the claim during the promptly period.

25 Medicare Secondary Payer: Billing Codes

26 Occurrence Codes

27 Remark Codes

28 Medicare Secondary Payer: Benefits Exhausted

29 MSP Billing when Benefits Exhausted When benefits have been exhausted for the primary insurance, the claim is submitted to Medicare as primary with a 25 occurrence code with the date the benefits exhausted and remarks for liability, no-fault or workers' compensation situations only. Beneficiaries who are covered under a Group Health Plan (GHP) for which the benefits have exhausted should submit their claims in accordance with the MSP guidelines.

30 Medicare Secondary Payer: Discover Primary Payer After Billing Medicare

31 Discover a Primary Payer after Billing Medicare as Primary The Provider must withdraw all claims/liens against liability insurance (except for claims related to services not covered by Medicare and for Medicare deductibles and coinsurance) when it bills Medicare. What happens if the Provider discovers a Primary Payer after billing Medicare? The act of billing Medicare limits the payment that the Provider may receive for the services billed to the Medicare approved amount. This applies even if Medicare did not pay the claim or the Provider refunded the Medicare payment to Medicare.

32 Discover a Primary Payer after Billing Medicare as Primary (Cont d) If the Provider collected on a claim/lien after billing Medicare, then: The Provider must refund the Medicare payment in instances where the amount collected on the claim/lien is for the full charges of the claim/lien and the Medicare payment is greater than or equal to the full charges of the claim/lien and greater than or equal to the amount collected on the claim/lien (Ex. 1). Example one: Charges from the facility are $5,000. Medicare is billed. The facility receives $8,000 from Medicare. The facility receives $5,000 from the liability insurance. The facility must repay Medicare $8,000. OR

33 Discover a Primary Payer after Billing Medicare as Primary (Cont d) If the Provider collected on a claim/lien after billing Medicare, then: The provider must refund the lesser of the amount collected on the claim/lien or the Medicare payment in instances where the amount collected on the claim/lien is less than the full charges of the claim/lien due to policy limits (Ex. 2); and The provider must refund to the beneficiary the difference between the amount collected on the claim/lien and the Medicare payment if the provider received payment for services not covered by Medicare and for Medicare deductibles and coinsurance (Ex. 3); or The provider must refund to the beneficiary the difference between the amount collected on the claim/lien and the Medicare payment less any amounts due from the beneficiary for services not covered by Medicare and for Medicare deductibles and coinsurance (Ex. 4).

34 Discover a Primary Payer after Billing Medicare as Primary (Cont d) Example two: Charges from the facility are $150,000. Medicare is billed. The facility receives $110,000 from Medicare. The facility receives $100,000 (due to policy limits) from the liability insurance. The facility must repay Medicare $100,000. Example three: Charges from the facility are $1,000. Medicare is billed. The Medicare allowable is $ The Medicare deductible has been satisfied. The Medicare coinsurance of $ has been paid. There are no charges for non-covered Medicare services. The facility receives $ from Medicare. The facility receives $1,000 from the liability insurance. The facility must repay Medicare $ and send $ to the Medicare beneficiary. Example four: Charges from the facility are $1,000. Medicare is billed. The Medicare allowable is $ The Medicare deducible has been satisfied. The Medicare coinsurance of $ has not been paid. There are $50.00 in charges for non-covered Medicare services. The facility receives $ from Medicare. The facility receives $1,000 from the liability insurance. The facility must repay Medicare $ The facility may retain $ for the unpaid Medicare coinsurance and charges for the non-covered Medicare services. The facility must send to the Medicare beneficiary the remainder of the liability insurance payment ($150.00).

35 Medicare Secondary Payer: Medicare s Subrogation Right

36 Subrogation (a/k/a Medicare Superlien) The substitution of one person in the place of another with reference to a lawful claim, demand or right, so that he who is substituted succeeds to the rights of the other in relation to the debt or claim and its rights, remedies, or securities. Subrogation denotes the exchange of a third person who has paid a debt in the place of the creditor to whom he has paid it, so that he may exercise against the debtor, all rights which the creditor, if unpaid might have done.

37 Lifecycle of a Medicare Secondary Payer Account

38 Patient Gets Injured Hospital Treats Patient Med Pay PIP Third Party Liability Medicare ACCOUNT IDENTIFICATION: The billing office staff must bill The claims billing for office which staff will work claims involved Bill submitted to Medicare as Registration staff identifies the auto account insurance as med-pay, workers in litigation comp, and to gather information needed secondary to bill payer using proper 2-part accident related; Patient completes premises MSP med-pay benefits are any available liability to insurance carriers or file hospital explanation code Questionnaire. those carriers prior to submitting liens to if Medicare. necessary. Liability coverage MUST be billed prior to submitting claim to Medicare.

39 Medicare Secondary Payer: Things to Remember

40 Section 111 (MMSEA) Mandatory Reporting Requirements (July 1, 2009) Add reporting rules; do not eliminate any existing statutory provisions or regulations. The new provisions DO NOT eliminate CMS existing processes if a Medicare beneficiary (or his/her representative) wishes to obtain interim conditional payment amount information prior to a settlement, judgment, award, or other payment. Includes penalties for noncompliance. Who must report: an applicable plan.... [T]he term applicable plan means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan or arrangement: (i) Liability insurance (including self-insurance). (ii) No fault insurance. (iii) Workers compensation laws or plans. What must be reported: the identity of a Medicare beneficiary whose illness, injury, incident, or accident was at issue as well as such other information specified by the Secretary to enable an appropriate determination concerning coordination of benefits, including any applicable recovery claim.

41 The MSP Questionnaire As a Medicare provider, you must determine whether Medicare is the primary or secondary payer for each inpatient admission or outpatient encounter prior to submitting a bill to Medicare. You can do this by asking Medicare beneficiaries about other coverage. CMS developed an MSP questionnaire for providers to use as a guide to help identify other payers that may be primary to Medicare. For the MSP Questionnaire provided by CMS, please visit MSP Manual, Ch. 3, Sec You should retain a copy of completed MSP questionnaires in your files or online for 10 years. You may keep hard copy files, optical image, microfilm, or microfiche. If you store these files online you must keep both negative and positive responses to questions.

42 Conclusion

43 Importance of MSP Billing Compliance 100% Review Fail to file correct and accurate claims with Medicare Federal law permits Medicare to recover its conditional payments. Medicare can fine providers, physicians, and other suppliers up to $2,000 for knowingly, willfully, and repeatedly providing inaccurate information related to the existence of other health insurance or coverage.

44 Questions???

45 Contact Information: Chad Powers, Esq. Vice President and General Counsel Medical Reimbursements of America, Inc Carothers Parkway Franklin, TN (615)