Integrity  Service  Solutions

1. Baker Newman Noyes Medicare ComplianceRegistration / Patient Access Integrity ServiceSolutions

2. Medicare • Health insurance for US citizens and lawfully admitted aliens (residing in US five consecutive years) • Administered by the Centers for Medicare & Medicaid Services (CMS) • Social Security Administration (SSA) determines eligibility for most beneficiaries. • Railroad Retirement Board (RRB) oversees railroad retirees

3. Medicare Entitlement Title 18 of the Social Security Act: • People ages 65 or older. • People under the age of 65 with certain disabilities. • People of any age with End Stage Renal Disease requiring dialysis or transplant • People of any age with Lou Gehrig’s Disease

4. Registration /Admission • Hospitals during the registration process often : • Obtain a signature authorizing billing to Medicare • Obtain a signature authorizing release of medical information • Obtain a signature; consent to treat • Staff will interview the patient; documenting replies to the Medicare Secondary Payer (MSP) questionnaire • Provide patient notices of non-coverage when appropriate • For Inpatient: • Provide the Medicare patient may be provided with the R193 –patient rights • Hospitals obtain the signature for patient election to use LTR days • CMS recommends before coinsurance days have been exhausted

5. Registration • Types of service • Outpatient • Includes observation status • Non-patient • Lab specimen • Inpatient • Formal inpatient admission order

6. There are four parts to Medicare • Part A – Hospital Insurance • Entitlement • Part B – Medical Insurance • Optional, premium paid • Part C – Advantage Plans • Alternative • Part D – Prescription Drug Coverage • Optional, premium paid

7. HEALTH INSURANCE MEDICARE SOCIAL SECURITY ACT Name of Beneficiary John D. Doe Medicare Claim Number Sex 123-45-6789A Male Is Entitled To Effective Date Hospital Insurance (Part A) 1-1-95 Medical Insurance (Part B) 1-1-95 SignHere John D. Doe  Verify Medicare Eligibility

8. Issues to be Mindful of at Registration • Medicare can look different • Fee for Service (Traditional-Medicare Part A and Medicare Part B) • Usually requires a supplemental insurance to cover deductibles and copayments • Medicare Advantage - (Medicare Part C) • Out of pocket expenses but not necessarily needing a supplemental policy • Health Maintenance Organization (HMO) Plans • Preferred Provider Organization (PPO) Plans • Private Fee-for-Service (PFFS) Plans

9. Issues to be Mindful of at Registration • Managed Care Recipients (Medicare Advantage) • Prior authorization requirements • A plethora of insurers with all different benefit structures • Home Health enrolled Beneficiaries • Outpatient hospital services may need to be provided under arrangement • Hospice • Are services related to the terminal illness? • Hospital may need to contract with Hospice • Skilled Nursing Facility • Consolidated Billing • Hospital may need under-arrangement contract for payment of outpatient services • End Stage Renal Disease • Consolidated Billing for services related to treatment of ESRD services

10. Conditions of Participation • Hospitals adhere to and operate under the rules outlined in the Medicare conditions of participation (CoPs) • Example of conditions: • Maintain clinical records on all patients • Operate under hospital by-laws with respect to staff credentials and requirements • All patients are under the care of a physician • 24-hour nursing is always available • Maintains a utilization review plan

11. Provider Agreement • Hospitals who choose to participate with Medicare • CMS executes a formal contract • Mandates include but are not limited to: • Limiting what can be billed to the patient(medicare beneficiary) • Deductible/coinsurance • Patient services considered excluded from coverage; dental and cosmetic services • Maintain a system during the admission process to identify any primary payers other than Medicare • Bill other payers before Medicare

12. Medicare Secondary Payer (MSP) Medicare Secondary Payer – is a term used to explain when Medicare is not the primary insurer or responsible party. Laws with MSP Provisions: • OBRA, TEFRA, BIPA, DEFRA

13. Medicare Secondary Payer • MSP is the acronym used by Medicare when Medicare is not responsible for paying first • Commercial insurers refer to this scenario as “coordination of benefits”

14. Medicare Secondary Payer Categories associated with MSP situations: • Group health plans: • Working aged - 20 employees • Disabled - 100 employees • End Stage Renal Disease • Workers’ Compensation: • Work-related injuries • No-fault, liability and medical payments associated with automobile insurance • Liabilities due to other accident and injuries • Malpractice, slip and falls, food poisoning, etc. • Other Secondary Payer Situations: • Public Health Service, VA, Black Lung

15. The Working Aged Category • Patients are over 65 • Actively employed or spouse is actively employed and covered by an employer group health plan (EGHP) • 20 or > employees • Have coverage under Medicare Part A

16. Disability Category • Patient is under 65 • Entitled to Medicare on the basis of a disability (non-ESRD) • Covered by a large group health plan (LGHP) either through their own or spouse employment • 100 or > employees • Have coverage under Part A

17. End Stage Renal Disease (ESRD) • Entitled to Medicare based on ESRD • Covered under EGHP regardless of number of employees through employment of self or family member • 30-month coordination period • Includes patients covered under COBRA

18. Auto Insurance Category • Auto-medical (med-pay) coverage • Pays for all or part of medical expenses for injuries sustained in the use of, or occupancy of an automobile regardless of fault • Must be billed prior to submitting a claim to Medicare

19. Miscellaneous Categories • Injured on the job - Workers Comp • Federal government; such as grants - Federal Programs • Coverage under the DOL program for diagnoses related to Black Lung Conditions • Coal Miners Disease

20. Veteran’s Administration • Medicare or VA are patient options • VA may authorize a VA to receive care from a non-VA hospital • No payment may be made by Medicare for VA authorized services • Patients may choose to receive care at a non-VA hospital • Insurance: one or the other (not both)

21. Liability Category • Any source which provides payment based on legal liability for injuries, illness or damages to property • Includes • Automobile • Uninsured Motorists • Homeowners • Product liability • Wrongful death

22. Medicare Secondary Payer • CMS requires that providers investigate all options to determine if Medicare is the secondary payer: • Use the CMS questionnaire or develop an internal tool • Answer; document each patient response • MSP Questionnaire once completed will instruct a provider: • When to bill Medicare as primary payer • Identify the responsible insurer or entity for billing • Provide incidental MSP related information to support billing .

23. Medicare Secondary Payer • MSP Questionnaire as a hospital record: • Retain for 10 years • Supports CMS right to “discover” for legal purposes

24. Medicare Secondary Payer • Frequency of questionnaire: • Required for each provider encounter except: • Referenced lab (non-patient) • Recurring, repetitive service accounts • Specifically defined by Medicare as repetitive services such as PT, OT, ST, Lab, Cardiac rehab, pulmonary rehab, etc. • MSP information pertaining to patient may not be greater than 90 days old

25. Questions Related to MSP 1. Are you receiving Black Lung (BL) Benefits? • Date benefits began: MM/DD/CCYY 2. Are the services to be paid by a government research program? • Yes, where should bill be sent 3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility?

26. Questions Related to MSP 4. Was the illness/injury due to a work-related accident/condition • Date of injury/illness: MM/DD/CCYY • Name and address of workers’ compensation plan (WC) plan • Policy or identification number: ____________ • Name and address of your employer 5. Was illness/injury due to a non-work-related accident? • Yes; Date of accident: MM/DD/CCYY

27. Questions Related to MSP 6. Is no-fault insurance available? (No-fault insurance is insurance that pays for health care services resulting from injury to you or damage to your property regardless of who is at fault for causing the accident.) • Yes, Name and address of no-fault insurer and insurance policy owner, policy number • Is liability insurance available? (Liability insurance protects against claims based on negligence, inappropriate actions or in-actions which results in injury to someone or damage to property) • Name and address of liability insurer, responsible party, insurance claim number

28. Questions Related to MSP 8. Are you entitled to Medicare based on: • Age • Disability • End-Stage Renal Disease (ESRD) 9. Are you currently employed? • If yes, name and address of employer • Date of retirement: MM/DD/CCYY

29. Questions Related to MSP 10. Do you have a spouse who is currently employed? - Yes, name and address of your spouse's employer - No, date of retirement: MM/DD/CCYY - No, never Employed Do either of you have group health plan (GHP) coverage based on your own or a spouse's current employment? How many employees?

30. Questions Related to MSP ESRD • Do you have group health plan (GHP) coverage? • Yes, name and address of GHP, insurance policy identification • Have you received a kidney transplant? • ___ Yes. Date of transplant: MM/DD/CCYY • Have you received maintenance dialysis treatments? • ___ Yes. Date dialysis began: MM/DD/CCYY

31. Questions Related to MSP • Are you within the 30-month ESRD coordination period? • The 30-month coordination period starts the first day of the month an individual is eligible for Medicare (even if not yet enrolled in Medicare) because of kidney failure (usually the 4th after onset of dialysis). • If patient is in a self-dialysis training program or has a kidney transplant, the 30-month coordination period starts with the first day of the month in which dialysis begins or when patient receives a kidney transplant.

32. Medicare Secondary Payer • A reply to each and every question is required • Answers / Defaults-rules for the recording of retirement dates • The beneficiary cannot recall his/her retirement date but knows it occurred prior to his/her Medicare entitlement dates, as shown on their Medicare card, hospitals report his/her Medicare A entitlement date as the date of retirement. • The beneficiary worked beyond his/her Medicare A entitlement date, had coverage under a group health plan during that time, and cannot recall his/her precise date of retirement. • The hospital determines it has been at least five years since the beneficiary retired, the hospital enters the retirement date as five years retrospective to the date of admission or service OTHERWISE, CONSIDER CALLING THE EMPLOYER

33. Important MSP Billing Codes • Examples of reportable Occurrence Codes with dates: • 01 - Date of accident • 02 - Date of accident - no fault • 03 - Date of accident - TORT Liability • 04 - Date of accident - work related • 05 - Date of accident - no liability/other insurer • 18 - Date of retirement - patient • 19 - Date of retirement - patient’s spouse • 24 - Date insurance denied • 25 - Date primary insurer benefits were exhausted • 33 - 1st day of ESRD coordination period

34. Important MSP Billing Codes • Value codes… examples • 12- Working Aged beneficiary/spouse with an EGHP (beneficiary over 65). Beneficiary must have Medicare Part A entitlement for this provision to apply. • 13- ESRD beneficiary in an MSP/ESRD 30-month coordination period with an EGHP • 14- No-Fault including automobile/other. Examples: Personal Injury Protection (PIP) and Medical Payment Coverage. Requires OC 01 or 02. • 15- Workers Compensation (WC). Requires CC 02 and OC 04. • 16- Public Health Services (PHS) or other federal agency • Conditional billing does not apply • 41- Federal Black Lung (BL) Program • 42- Veterans Administration (VA). Conditional billing does not apply.

35. MSP Billing Provider Responsibility • Patient Access serves a critical role in securing health insurance information from patients • Update insurance information at each encounter • Develop policies for making a good faith effort to determine the primary and secondary insurer

36. MSP Compliance • Compliance with MSP regulations is mandatory • Non-compliance • May find for hospital violation of Mandatory Claim Submission Laws • Loss of contract to provide services to Medicare patients • Subject to close scrutiny and additional provider audits

37. Questions

38. Contact Information Maggie Fortin Senior Manager Baker Newman Noyes 280 Fore Street Portland, ME 04112 (207) 791-7547 (direct line) mfortin@bnncpa.com (800) 244-7444 (207) 774-1793 (fax)