Medical Bill dispute - How to avoid and how to resolve

The crucial Guide of Disputing Medical Bills or Insurance Policy (Complete Guide)

Over the years, the majority of the folks are encountering complicated issues with medical billing.  Therefore, it is highly recommended that you have to know how to dispute a medical bill or denied insurance. Fixing errors in medical bills can be challenging as one need to follow the complete procedure.  These days, lots of people are frustrated with expensive hospital bills.  Thus, it is your responsibility to invest proper time in the proper analyzation and find out the errors in the bills.

For dispute, a person should make contact with a hospital and Fix the errors.  If you want to dispute a medical bill effectively then firstly you should find out the errors.  In order to know more regarding Disputing medical bills or denied insurance policy, then you should read forthcoming paragraphs properly.

Steps to be taken to resolve

How to review your Medical bills.

* All you need to review your bills. Make sure that you are analyzing all the parts in the statement invoice or medical bills. Most of the hospitals are charging a lot of additional costs like full-day rate of the room and other charges. 

* Check all the procedure code which they mentioned in invoice . Most of them cost based on the time and hence double verify the time you spend with provider and what is mentioned in the invoice.

* Check how much insurance are paid and what the left over from the insurance . Compare with insurance EOB.

* If any non covered service from insurance then you need to make contact with an insurer and get to know regarding the coverage.  Make sure that it is covering all the legitimate charges with ease.  A professional call will able to resolve the claim dispute with ease. 

* After that, you have to invest a significant amount of time in the research and check the fair price of medicines or injections.  If you want to raise any dispute, then it is your responsibility to show any proof.  All you need to make a relevant comparison and find out the Fair price of each medicine or other materials.

* You should have paid copay , coins, insurance Deductible and other patient responsibilities  at the time of visit but they charged again.

If you find any mismatch, follow the below procedures.

Make contact with a hospital

In order to raise the dispute, then it is your responsibility to call the hospital. All you need to share the biggest errors and what you find in he bills.  You need to keep essential notes like Name of the Person, and other crucial details like receipt which you paid or EOB reference regarding the bill. 

Most of the time the problem and dispute would be solved just by calling them directly.

Finance help - Make a call with Doctor office Manager or Billing office.

If possible, then the user should make contact with a doctor office manager and discuss problems with him.  Lots of medical office are offering financial assistance programs which are helpful for those who are raising the disputes.  According to professionals, almost 90% of the medical bills are associated with some sort of mistakes.  It is really dangerous that is creating a big hole in the pocket.

Sample Medical Dispute letter
Disputing complicated mistakes on the medical bill isn't the task of the kids as you need to invest proper time and efforts in the correction.  Make sure that you are following the proper terms and conditions. If you don't have proof, then you will not be able to get the claim.  It would be better to find out the sample medical dispute letter and raise a particular dispute. Make sure that you are sending a particular dispute letter to the billing department.  Lots of disputes are always associated with honest mistakes. According to professionals, you will able to dispute solved if you a claim within 90 days. 

Self Pay – No insurance cases

Before raising any dispute, the patient should pay close attention to the law of the state. Most of the hospitals are overcharging from the self-pay patient. Therefore, it would be better to obtain a particular sample of allowed amount for that procedure mainly Medicare. After that, you have to attach essential copies along with a letter. If you are providing proof such receipts, fee schedule document, then one will able to get the dispute very easily.

Currently, if you don't have any Insurance policy, then it would be better to pay the bill via Cash. Lots of healthcare providers are giving a discount to every customer.  If you are negotiating, then it would be better to initiate with a lower offer.

Raise a particular complaint

It is highly recommended that you should take the dispute to another level.  If a claim is expensive, then you must find out the insurance codes from the bills and allowed amount from the common insurance.

Going to attorney

Its not advisable to attorney for small amount, If you want to avoid the hassle, then you should hire a personal attorney who would be helpful for you.  Before hiring any advocate, one should discuss the fee with him/her. Majority of the lawyers are charging a fee on an hourly basis. User will able to find a personal lawyer from the Internet

How do I dispute an old medical bill?

Want to dispute Old medical bills? You will able to rise for the dispute, but chances of success are relatively lower.  Make sure that you are following the proper rules & regulations of the hospital. For effective outcomes, one should make contact with a debt attorney who will assist you in raising the dispute against old medical bills.  If you have evidence, then you will able to get the dispute solved.  According to professionals, it is a little bit complicated or lengthy process to obtain the claim. You have to fight with the hospitals.  It is your responsibility to make contact with the hospital related to the dispute. It would be better to grab a complete copy of incorrect bills with them.

Proper research is mandatory

Before initiating any dispute, it is your responsibility to invest proper time in the research.  You should check the current worth of medicines, injections, and other things. If you want to claim instantly, then the user must make contact with an anesthesiologist office.

Moving further, if you don't want to invest precious time in the research, then the user should find out a personal attorney who will able to raise the dispute.  An experienced lawyer would be helpful  in filing a particular appeal.  He will surely file the complaint according to the proper instructions.

Avoiding Dispute tips

Always keep the all the records related healthcare whether its from insurance, hospital or Doctor office receipt. That would solve most of the problem and most importantly your time.

Medical billing specialist salary - How much they can earn and requirements

Medical billing specialist salary

Becoming a proficient medical biller isn't easy as one should invest proper time in learning.  Specialists are relatively expert in verifying medical bills, claims and insurance and patient invoices.  Being a medical biller, it is your responsibility to invest proper time in the internship. This particular job requires a lot of important things, and basic degree and certificate in code or billing specialist.

 According to professionals, a proficient medical biller is getting anywhere between $3k to $6k (Big practice, big companies and hospitals) per month as salary.  No doubt, salary depends on a lot of important facts like certifications, additional skills, and education as well mainly with experience and your position.  Therefore, a person must grab certificate courses and increasing the knowledge in different domain that is proven to be mandatory. After becoming a proficient medical biller, one will able to work on not paid aged claims and which would be making him specialist.

So we could tabulate the Medical billing specialist salary as below, All are given per month.

1. Entry level - $2.5k - $3.5k ( Hourly basis too)
2. Mid level - 4.5k - $5k
3. Experience level - Specialist in one area - $6k and More

 How much does a medical billing specialist make an hour?

According to researchers, coders or medical billers are high in the demand.  They are making $16.42 per hour.  Federal Government is offering a lot of incentives to the potential users to attract more people in the company. In order to become a proficient medical biller, then you must be pass out from the college.   Medical billers are growing with at least 20%.  It is a little bit tough job where the user needs to maintain the patient records and handling the medical records, scheduling patients and entry job as well. If you are Medical coder need to be proficiency with CPT and ICD 10 code and insurance coverage policy according to thier edit.   They have to analyses super billing and visit note and covert into codes according to the history of treatment and diagnoses as well.

The pay scale of Medical Billers

No doubt, wages of the medical billers is growing continually.  A professional or experienced medical biller is earning $34,160 yearly. All things depend on the location, level of experience, and skills.  Top medical billers are earning almost $56000 each year. If you are one who wants to become a proficient college degree, then a college degree is required to enroll in the job. After that, it is your responsibility to invest a significant amount of time in learning through certification and get the required knowledge.

• How much do billers get paid?

You will find a lot of certified Hospitals, which is employing the proficient Medical billers to calculate the overall worth of the services.  They are preparing essential bills and sending them to the insurance and patients.  Proficient billers are already familiar with a lot of important things like fee structure and other CPT , ICD codes.  They have an answer to every question related to the denial management.  Most of the professional medical billers are working in surgical or general hospitals.

It is a great opportunity for those who want to complete their studies, along with work.  Medical billing system totally depends on the medical coders. Insurance coverage is making the use of essential codes for the coverage. Salary of a medical biller always depends on the certifications, level of experience, skills as well. If you want to maximize the salary, then it is your responsibility to complete an essential program. As we previously said salary is totally differ to person to person.

Requirement for Medical billing specialist

Following are some essential things that will assist you in becoming a proficient medical biller specialist.

* Level of Qualification

Majority of the small clinics are hiring the coders or billers without prior experience and high level of education.  They are just asking for the certificate training program only. You will able to complete specific training using online websites. Lots of colleges or technical schools are out there where one can learn regarding medical terminology.  This specific program is associated with basic information related to physiology and human anatomy.

** Requirements of career

A person must obtain medical coding and billing degree, which is proven to be essential for a newbie. All you need to find out a perfect institution from where you can learn more regarding codes and another medical billing process. I dont say its must but it helps to get the job easily.

** Education qualification

A medical biller must have essential things like a post secondary certificate and an essential degree as well.  These crucial things will assist you in earning more salary.

** Certifications

If you are obtaining at least one or two coding and billing certification, then you will be surely able to earn a lot of money.  Experienced and skilled persons are also earning huge amount of money. Certification course usually take  6- 12  months.

AR specialists specialize in one or more of the following areas:

• Claims reviewer. Provides expert advice to healthcare providers.

• Coding reviewer. Prepares claims for doctors to submit to the claims. Checking ICD and CPT combination and document verification.

** Experience is must

After getting the degree, it is your responsibility to invest proper time in the internship and get the experience in all domain charge entry, payment posting, denial management with medical code knowledge. Additional training has become mandatory for those who want to become a proficient medical biller.

Is it easy to get into Healthcare industry ?

Absolutely No, These days, lots of organizations are making the use of Paper-based system that is a little bit complicated and time-consuming. Some clinics or hospitals are packed with thousands of patients.  Neither Doctors nor their staff has time for such a tougher task. Therefore, lots of hospital and clinicians are opting for medical billing and coding process.  According to professionals, certified medical billing companies are investing a significant amount of time in the precious HER technology as it is quite better than others. 

Medical billing and coding both are different things.  To become a professional medical biller, then the user needs to invest proper time in the learning.  You need to consider various diagnosis and procedure as well.  Here I have recapitulated vital things related to medical billing and coding where you have a glance.

How is Job Growth ?

Medical billers are on its hype, and a potential biller is earning a significant amount of money. If a person has knowledge related to crucial codes, then he/she will able to become a perfect medical biller with ease.  It is considered a little bit tough task where you need to maintain the significant amount of information in the records. Hospitals are making the use of electronic health records.

Conclusive words

Lastly,   Medical billing has become one of the most important things in hospitals. For such a process, every hospital is looking for the proficient biller.  They are keeping the records and giving information to the insurance companies for the coverage.  Sometimes, hospitals are paying a little part of the insurance, which is known as co-paying.  Along with codes, you have to make the use of software where one can easily keep the records.

Medical billing (RCM) Process - step by step explained

An efficient RCM process in medical billing can enhance medical practice revenues.
The primary job of any medical practice is to provide the best medical care to ensure positive results. However, bogged down by numerous administrative procedures that include insurance verification, charge entry processing, claim submission process etc, it is becoming increasingly difficult to keep a firm focus on what matters the most, restoring the health of the patient.

Enter medical billing specialists at this stage. These are trained professionals who ensure that billing, coding, claims processing happens smoothly in a process called revenue cycle management (RCM).  Read on to take a closer look at what is the RCM process in medical billing. To understand the RCM process, we will have to begin by telling you what are the steps in medical billing process. Let’s go step by step to understand the process in detail.

Process involved in Medical billing

1. The patient makes an appointment

The RCM process kicks in at the time that a patient himself or his family seeks an appointment at a medical care facility. Upon receiving the call, an employee from the medical care facility provides a confirmation of the appointment, gets the details and makes a record of the demographics and the insurance information of the patient in the RCM software that is installed inhouse, if the medical care facility is small or is outsourced to a revenue cycle management company if it is a larger organisation or a hospital network in question, this job is outsourced to a RCM company.

2 Insurance Verification Process

Once you confirm the appointment and get the patient information. We should validate the patient insurance information either by checking online and calling the insurance directly. Also get copay, deductible and out of pocket information. Only if the insurance is active we could confirm the patient appointment otherwise call patient and inform them what is wrong and get clarified. In this stage we have to get the pre authorization too if the procedure required.

3. The patient’s arrival

Once the patient arrives for the appointment, he undergoes some pre-checkup and updation of medical records according to his specification and prescription drugs, procedures, services and all information has been recorded.  The best practices here is, collect all copay, deductible and previous visit balance billing if any. This would avoid lot of billing process and billing life would be easier. Once these payments are made, they are recorded in the RCM system, under the patient’s account.

Tip: Patient payment information has to be conveyed to patient during the appointment confirmation stage itself.

4. Creation of superbill.

The doctor examines the patient and specify all diagnosis and treatment information into filling out a superbill on the RCM system. This could be either paper super bill or electronic super bill which doctor enter the CPT and DX in the RCM software itself.

5. Review of the superbill and entering the charges

The medical coding or RCM specialist reviews this super bill at this stage, to ensure that the correct ICD codes, CPT codes and modifiers have been used according to patient visit notes (Medical records). In case any changes are required, the doctor is informed and to make the modifications as necessary. Most of the providers only entering description of the services and Diagnosis. Hence choosing right ICD code matching with CPT code is key element here.

6. Claim submission process

After the superbill has been entered by the RCM team, the billing software kicks into action and sends it to the clearing house for a final review.  If there are any mistakes in codes at this stage, the clearing house sends the claim back as rejection. Only if the claims have been successfully passed through and reach the insurance with acknowledgment report make the claim submission process complete. If all the codes match correctly and patient is active during that time, the bill is sent on further for processing of claims. If the insurance company finds errors or a lapse at this stage, the claim would be denied at this stage. A good RCM company under the supervision of a qualified medical billing specialist has a 98-99% success rate in the first pass claims acceptance ie clean claims.

7. Payment posting and denial management

Once all the approvals are in place, it is time for the insurance company to make the payments. Post claims acceptance and processing, the practice receives that payment. After the receipt of the payments the RCM team reconciles the payment under the patient’s account.  Posting under correct patient and correct DOS is main requirement here. If we choose anything wrong, the system balance would not tallied correctly and that give us indication to choose the right patient and DOS, CPT.

Tip: Choosing the correct denial would reduce the lot of unnecessary work. Educate the team in that manner.

8. AR & RCM process.

This would be most complicated process in RCM process as we don’t have anything to enter or do the quality check-up but need to take the action on non-paying claims. Not all the claim which we submitted to insurance would automatically paid hence we have to run the report of non-paying claims (Aged claims) and do the follow up with insurance is main process here. Unless we call the insurance and ask the status some of the claims will not be paid at all. Hence follow up with insurance is must process.

Tip : The good practice is review of unpaid claim every 15 days. Some action has to be taken on every 15 days in each and every single unpaid claims

Why following medical billing process improve the revenue

Trusting a reputed medical billing service provider who follows the correct process may seem expensive but it is what efficiently streamlines the RCM process for your practice to navigate through the complicated  medical billing procedures. These service providers provide end-to end services right from reviewing patient eligibility and payments, recording, coding, reviewing and final submission for a smooth claim processing.

With an efficient RCM partner at your service you never have to worry about unnecessary financial losses due to lapses in the medical billing process. Further, with 24x7 back end support, you can rely on an expert to guide you through and solve technological glitches if any in the system. In this hyperconnected age, if you are a medical care practitioner it makes financial sense for you to invest in either efficient RCM software or outsource the process to a medical billing services provider at the earliest.

CPT Category III Codes, definition, guidelines and examples

CPT Category III Codes

The following CPT codes are an excerpt of the CPT Category III code set, a temporary set of codes for emerging technologies, services, procedures, and service paradigms. For more information on the criteria for CPT Category I, II and III codes, see Applying for Codes.

To assist users in reporting the most recently approved Category III codes in a given CPT cycle, the AMA’s CPT website publishes updates of the CPT Editorial Panel (Panel) actions of the Category III codes in July and January according to the Category III Code Semi-Annual Early Release Schedule. This was approved by the CPT Editorial Panel as part of the 1998- 2000 CPT-5 projects. Although publication of Category III codes through early release to the CPT website allows for expedient
dispersal of the code and descriptor, early availability does not imply that these codes are immediately reportable before the indicated implementation date.

Publication of the Category III codes to this website takes place on a semiannual basis when the codes have been approved by the CPT Editorial Panel. The complete set of Category III codes for emerging technologies, services, procedures, and service paradigms are published annually in the code set for each CPT publication cycle.

As with CPT Category I codes, inclusion of a descriptor and its associated code number does not represent endorsement by the AMA of any particular diagnostic or therapeutic procedure or service. Inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy

1. What is a Category III CPT code?

Category III CPT Codes are temporary codes for emerging technology, services and procedures that allow for specific data collection associated with those services and procedures. There are no assigned RVU’s or established payment for the Category II CPT codes. When these procedures become more commonly adopted and established, the societies will work with the American Medical Association (AMA) to move these codes from Category III to Category I CPT status.

Physicians will report the WATCHMAN LAA Closure procedure with Category III CPT Code: 0281T. The code descriptor for 0281T is:

Percutaneous transcatheter closure of the left atrial appendage with implant. Includes fluoroscopy, transseptal puncture, catheter placements, left atrial angiography, left atrial appendage angiography, radiologic supervision and interpretation.

2. How do Category III CPT Codes differ from Category I CPT Codes?

Category I codes have assigned relative value units (RVUs) or work values and have an associated payment amount. A Category III CPT code does not have assigned RVUs and therefore, there is no payment rate established and reimbursement is at the payer’s discretion. In addition, a Category III code does not require FDA approval whereas; procedures described by a Category I CPT code must have FDA approval.

3. In the interim, how do physicians work with payers in establishing an appropriate payment rate for the WATCHMAN LAA Closure procedure when they are reported with Category III CPT Codes? For physician services reported with a Category III CPT Code, providers will reference or crosswalk a procedure code with similar or equivalent resources (i.e., RVUs) as the WATCHMAN LAA Closure implant (i.e., suggested CPT codes include but are not limited to: 93580: transcatheter closure of atrial septal defect with implant or 93581: transcatheter closure of ventricular septal defect with implant). It will be important for the provider to document the services provided in regards to resources and time for appropriate consideration of the payment for the professional component of the procedure.

Recommended items to support your claims submissions include the following:

* Copy of operative report
* Letter of medical necessity
* Copy of the FDA approval letter (Boston Scientific can supply electronic copy)

Copy of relevant published clinical literature supporting the use of the WATCHMAN LAA Closure System If physicians are employed by the hospital and their compensation is based on productivity from an RVU tracking methodology, it is important to work closely with the hospital administrators in benchmarking WATCHMAN LAA closure procedures to a procedure with established RVU’s utilizing similar resources, time, competency and risk. These discussions should happen in advance of a WATCHMAN implant being performed.

Guidelines for using Category III Codes
Unless an NCD, LCD or coverage article is published to address coverage for a specific Category III CPT code, UnitedHealthcare considers all services and procedures listed in the current and future Category III CPT code list as not proven effective and will deny submitted claims as not medically necessary. Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meeting all technical requirements for coverage, but are determined to be any of the following:

** Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used
** Not proven to be safe and effective based on peer review or scientific literature
** Experimental
** Not medically necessary in the particular case
** Furnished at a level, duration or frequency that is not medically appropriate
** Not furnished in accordance with accepted standards of medical practice, or
** Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician's office or home care) appropriate to the patient's medical needs and condition.
** Items and services must be established as safe and effective to be considered medically necessary. That is, the items and services must be:
** Consistent with the symptoms or diagnosis of the illness or injury under treatment;
** Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental or investigational);
** Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier;
** Furnished at the most appropriate level that can be provided safely and effectively to the patient.

Example Category III Codes

CPT Code Description Noncovered

0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time

0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure) (See Medicare Advantage Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures)

0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for
primary procedure) (See Medicare Advantage Policy Guideline titled Stereotactic Computer Assisted Volumetric and/or Navigational Procedures)

0058T Cryopreservation; reproductive tissue, ovarian

0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue

0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume greater or equal to 200 cc of tissue

0085T Breath test for heart transplant rejection (Not Covered by Medicare) [See the Medicare Advantage Policy Guideline titled Heartsbreath Test for Heart Transplant
Rejection (NCD 260.10)]

0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0098T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy [See the Medicare Advantage Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)]

0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle [See the Medicare
Advantage Policy Guideline titled Extracorporeal Shock Wave Treatment (ESWT)]

0106T Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation

0107T Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation

0108T Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia

0109T Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia

0110T Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation

0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes

what is Medicare as secondary payer - different situation

Medicare Second Payer

Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about "Coordination of Benefits" when assigning responsibility for first and second payment.)

The term "Medicare Secondary Payer" is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the "gaps" in Medicare's coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program.

Precedence of Federal Law

Federal law takes precedence over State law and private contracts. Thus, for the categories of people described below, Medicare is the secondary payer regardless of state law or plan provisions. These Federal requirements are found in Section 1862(b) of the Social Security Act {42 USC Section 1395y(b)(5)}. Applicable regulations are found at 42 CFR Part 411 (1990).

More information on MSP laws and regulations is available through the CMS Laws and Regulations Portal. The link to the CMS Laws and Regulations Portal is located below.

Responsibilities of Beneficiaries Under MSP

As a beneficiary, we advise you to:
  • Respond to Initial Enrollment Questionnaire (IEQ) and MSP claims development letters in a timely manner to ensure correct payment of your Medicare claims,
  • Be aware that changes in employment, including retirement and changes in health insurance companies may affect your claims payment,
  • When you receive health care services, tell your doctor and other providers and the Coordination of Benefits (COB) Contractor about any changes in your health insurance due to you, your spouse, or a family member's current employment or coverage changes,
  • Contact the COB Contractor if you take legal action or an attorney takes legal action on your behalf for a medical claim,
  • Contact the COB Contractor if you are involved in an automobile accident, and
  • Contact the COB Contractor if you are involved in a workers' compensation case.

Responsibilities of Providers Under MSP

As a Part A institutional provider (i.e. hospitals), you should:
  • Obtain billing information prior to providing hospital services. It is recommended that you use the Centers for Medicare & Medicaid Services' (CMS') questionnaire, or a questionnaire that asks similar types of questions; and
  • Submit any MSP information to the intermediary using condition and occurrence codes on the claim.
As a Part B provider (i.e. physicians and suppliers)
  • Follow the proper claim rules to obtain MSP information such as group health coverage through employment or non-group health coverage resulting from an injury or illness;
  • Inquire with the beneficiary at the time of the visit if he/she is taking legal action in conjunction with the services performed; and,
  • Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process an MSP claim.

Responsibilities of Employers Under MSP

As an employer, you must:
  • Assure that your plans identify those individuals to whom the MSP requirement applies;
  • Assure that your plans provide for proper primary payments where by law Medicare is the secondary payer;
  • Assure that your plans do not discriminate against employees and employees' spouses age 65 or over, people who suffer from permanent kidney failure, and disabled Medicare beneficiaries for whom Medicare is secondary payer; and,
  • Accurately complete and submit Data Match reports timely on identified employees.

Group Health Plans (GHP)

An employer cannot offer, subsidize, or be involved in the arrangement of a Medicare supplement policy where the law makes Medicare the secondary payer. Even if the employer does not contribute to the premium, but merely collects it and forwards it to the appropriate individual's insurance company, the GHP policy is the primary payer to Medicare.

Responsibilities of Attorneys Under MSP

As an Attorney, you must:
  • Immediately, upon taking a case, that involves a Medicare beneficiary, inform the COB Contractor about a potential liability lawsuit, and
  • Contact the assigned lead contractor regarding Medicare's interest in a liability, auto/no-fault, or workers' compensation lawsuit.

Responsibilities of Insurers Under MSP

As a GHP insurer, you must:
  • Report to the COB Contractor if you find that CMS has paid primary when you are primary to Medicare (i.e. 411.25).
As a Non-GHP Auto/Liability Insurer, you must:
  • Contact the COB Contractor immediately when the individual you insure is a Medicare beneficiary.


Until 1980, Medicare was the primary payor for all Medicare covered services except for services covered by Workers Compensation or Black Lung benefits or paid for by the Department of Veterans Affairs or Other Government Entities. Since 1980, a series of changes in the Medicare law has shifted costs from the Medicare program to private sources of payment.

Federal regulations require healthcare providers to know when they can bill Medicare as the primary or secondary payer. Failure to properly determine the primary payer is a violation of the provider agreement with Medicare. Medicare considers it a fraudulent and abusive practice when a provider regularly submits claims that are the responsibility of another insurer under the MSP provision
Presently, Medicare is the secondary payer for individuals

Ø Who are aged 65 or older and currently working with coverage under an employer-sponsored or employee organization group health plan,

Who are aged 65 or older and are covered by a working spouse’s EGHP or employee organization group health plan,

Ø Who are under age 65, disabled, and are covered by a LGHP due to their own or other family members current employment status,

Ø Who receive services covered under Workers Compensation, Federal Black Lung, Automobile, No-Fault, or Liability insurance plans

Ø Who receive services covered under the Veteran Administration

Beneficiaries entitled to Medicare solely on the basis of ESRD, during a 30 month coordination period

Ø Working Aged

Top Medicare billing tips