Medicare Secondary Payer
- Provider Admission
(Hospital, Skilled nursing, Doctors office and Rehabilitation facilities)
Providers are required to ask Medicare beneficiaries a series of questions with each admission to determine if Medicare is the primary or secondary payer. These questions include but are not limited to:
Employment status - You must provide the name and address of your employer if they pay for a portion of your health insurance. Also, provide the name and address of your group insurance.
Employer Group Health Plan (EGHP) - If you are over the age of 65 and meet the criteria listed above, your group health insurance must have at least 20 employees to be considered the primary payer.
Large Group Health Plan (LGHP) - If you are under the age of 65 meet the criteria listed above, your group health insurance must have at least 100 employees in the plan to be considered the primary payer.
If you are retired, please give your retirement date.
If you are covered under your spouse, please provide the information as described above related to your spouse.
If you have never been employed and do not have group insurance, please let the provider know and Medicare will be billed as the primary payer.
End Stage Renal Disease (ESRD) - If you are within the 30 month coordination period for ESRD, please give the provider the name and address of your group insurance and the name and address of the employer. During the 30 month coordination period Medicare is secondary.
Auto/Liability - If you have been in an automobile accident or any type of liability situation where another entity should pay as primary. If at the time of admission you are unsure of who the other payer should be, give the provider any information you have and they will bill Medicare on the condition that Medicare will investigate the claim further.
Any information you can provide during the admissions process will help the claims to process more effectively.
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Recovery Process when Medicare paid as primary and another entity is responsible for payment (liability situation).
Please note, Section 1862(b) of the Social Security Act, grants Medicare a priority right of recovery. Section 1862(b) also gives the Medicare Program the right of subrogation under section 1862 of the Act. In order to recover the conditional payment, Medicare may bring direct action in its own right against the entity responsible or required to repay Medicare, or against any other entity that has received payment.
When a Medicare beneficiary enters a hospital, skilled nursing facility, doctors office or a rehabilitation facility, the provider has the option of billing Medicare or the other entity responsible for payment of the bill. This could be any of the following:
Automobile, Medical or no-fault Insurance:
Insurance coverage (including a self-insured plan) that pays for all or part of the medical expenses for injuries sustained in the use of or occupancy of an automobile, regardless of who may have been responsible for causing the accident (This coverage is sometimes called "Personal Injury Protection" (PIP), or "Medicare Expense Coverage").
Liability Insurance:
Insurance (including a self-insured plan) that provides payment based upon legal liability for injuries, illness, or damage to property. It includes, but is not limited to automobile liability, malpractice insurance, product liability insurance and general casualty insurance. It also includes payments under a state's "Wrongful Death" statutes that provide payments for medical damages.
Self-Insured Plan:
A plan under which an entity (or an individual) is authorized by state law to carry its own risk instead of insuring itself with a carrier.
Uninsured Motorist Insurance:
Insurance under which the policyholder's insurer will pay for damages caused by a motorist who has no automobile liability insurance or who carries less than the amount of insurance required by law or is underinsured.
Below are the steps taken to resolve a potential receivable through the Medicare Program.
- Medicare is made aware if the liability, no-fault or worker's compensation situation.
Attorneys, insurers, and beneficiaries are required to notify Medicare of liability, no-fault, or worker's compensation situations where another entity may be the primary payer, the Medicare contractor will coordinate with all Part A and B Medicare offices to determine the amount of payments made related to the liability accident/incident. This coordination effort to determine all Medicare payments can take up to twelve weeks. Therefore, it is important to notify the Medicare Program as soon as possible of a liability, no-fault, or worker's compensation situation. At this time Medicare will ask for a signed authorization from the beneficiary, their Power of Attorney, or legal guardian stating we can release detailed payment information to the either the attorney or insurance. If this is not received, Medicare will only release the amount due to the Medicare program. Once the authorization is received, detailed payment information, including the dates of service, provider name, total charges, amount paid by Medicare, and diagnoses codes will be released.
Page Last Updated: Thursday, 17-Jul-2008 10:11:30 CDT
