CMS is undertaking a comprehensive effort to collect money owed to Medicare due to incorrect payments related to coordination of benefits. The result is that providers often learn of group health coverage by way of a letter requesting repayment of an incorrect Medicare payment. This puts providers in the tenable position of either writing off related balances or filing insurance claims with group health plans long after the health plan’s filing deadline has passed.
Prevention of MSP denials can be achieved by making every effort to identify all payers potentially responsible at the time of treatment. Medicare law and regulations requires providers to file correct and accurate claims with Medicare using billing information obtained from the beneficiary to whom the item or service is furnished. Reporting the availability of other health insurance is a required element of Medicare claim submission. Additionally, 42 CFR 489.20(g) requires that all providers must agree “… to bill other primary payers before billing Medicare …” Thus, any provider that bills Medicare for services rendered to Medicare beneficiaries must determine whether or not Medicare is the primary payer for those services. This is accomplished by asking Medicare beneficiaries or their representatives, questions concerning the beneficiary’s MSP status. If providers fail to file correct and accurate claims with Medicare, 42 CFR 411.24 permits Medicare to recover its conditional payments. Go to www.cms.hhs.gov/manuals/105_msp/msp105index.asp for the latest draft of Medicare’s Secondary Payer Manual where applicable policies and procedures are explained in detail and questionnaires are provided to facilitate complete insurance information collection.
Unfortunately, beneficiaries or family members providing insurance information sometimes provide incomplete information. Further, liability may depend on a number of factors not readily available at the time of treatment. For this reason, failure to identify the primary payer at the time of treatment does not necessarily allow a group health plan or other responsible party to avoid payment of the claim. Although most group health plans have some type of timely filing deadline, the deadline may not be applicable to a MSP claim.
Medicare MSP rules state that the group health plan does not have a valid timely filing defense if either the employer, the insurer, the TPA, or other responsible entity had knowledge within the plan’s timely filing period that the services were provided. One example of this situation would be if the Medicare intermediary was also acting as the insurer or claims payer for the group health plan. Further, group health plans cannot use the timely filing defense for at least three years from the date of service if the demand for repayment is made directly to the responsible entity by Medicare MSP contractors. See Section 4632 of the Balanced Budget Act of 1997. Although the Act does not specifically protect providers from the timely filing limitation defense on MSP claims, it implies that group health plans must maintain clear documentation of both the timely filing exclusion and be able to attest to the fact that no records of the services being provided to the beneficiary can be found.
Once a Medicare recovery demand letter has been received, the refund should be immediately made to Medicare and the claim submitted to the primary payer along with (1) billing information regarding the original filing date with Medicare (2) any available explanation about why primary coverage was not identified at the time of treatment and (3) a copy of the Medicare demand letter for payment of incorrectly paid benefits.
If the group health plan denies for lack of timely filing, you may want to appeal this decision citing the limitation of the timely filing defense contained in Section 4632 of the Balanced Budget Act of 1997. Appeal Solutions has added an appeal letter to the appeal letter repository to assist with this appeal. The letter is titled “Request for Primary Payment Subsequent to MSP Refund” and is filed under the Topic “Timely Filing” and the Subcategory “Notification of Timely Filing”
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