Medicare Secondary Payer – The Lost Opportunity

Your team here at SNF Solutions has noticed a trend of facilities either not filing or having problems with filing and collecting Medicare Secondary Payer (MSP) funds.  These are claims that should only be filed to Medicare after the Primary Insurance Payer, either makes a reduced payment or no payment and the resident is entitled to Medicare A or Medicare B benefits as the Secondary Payer.  Remember, these policies are not HMO or Medicare Advantage Replacement policies, which take the place of Medicare A or Medicare B Benefits.  They are insurance policies that are considered Primary to Medicare benefits and will be listed on Page 16 of the Common Working File (CWF) Benefit Eligibility Screen. Examples of Primary Insurance Payers include Working Aged, ESRD, Disability, VA, Worker’s Comp, Black Lung, Liability, No-Fault, or Medical Insurance related to an Accident Policies.

Unfortunately, these Primary Insurance Payers are often not properly identified prior to admission. This hole in the Admissions process results in a Medicare Primary Claim being submitted to Medicare A or Medicare B. The claim will then be rejected (R Status) or returned to provider (T Status) with an error code indicating that there is an open MSP record on the Common Working File (CWF).  The claim error code will inform the Business Office Manager (BOM) of their next steps.  Most often this will require submitting a claim to the Insurance Company first.

Once the claim is submitted to the Primary Insurance Company and either a Partial Payment or a Denied Payment is received with the appropriate Explanation of Benefits (EOB) attached, then the BOM should correct the previously denied or returned to provider claim that is on file in DDE and file it as a MSP Claim.  If upon admission of the resident, your BOM read the CWF Eligibility Request, correctly identified the MSP Payer, filed the appropriate primary insurance claim and has received either a Partial Payment or a Denied payment, then they should now submit a MSP Claim.

This is where difficulties most often arise in the billing process. Both inexperienced and even an experienced BOM can find it confusing to learn and master. This is because Medicare requires specific condition, occurrence, and or value codes, as well as detailed adjudication (prior payer) information to be included on the claims, either on the UB-04 or in DDE, in very specific formats.

Our staff at SNF-Solutions has successfully filed and received payment for clients by submitting clean accurate MSP Claims to Medicare.  We will be happy to assist you and your BOM in doing the same.  SNF-Solutions has developed a training platform which can assist your BOM and facility in collecting this difficult revenue.