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Don鈥檛 let confusion about where to submit a government payer claim derail your reimbursement.

Last month, RCI reported on the Office of Inspector General (OIG) audit that looked at claims submitted erroneously to Medicare that actually should have been billed to the Veterans Administration (VA), and similar government payer claim submission errors.

This month, find out what your practice should do to minimize the chances of submitting a claim to the wrong government payer. Your compliance and reimbursement may be on the line!

Do This to Assess Exposure

Although most of the OIG鈥檚 recommendations in the audit are directed at Medicare and the VA, there is much that providers can do to prevent erroneous Medicare billing and proactively identify duplicate payments:

1. Review credit balance claims with Medicare and VA (or other potential primary insurer) listed on the account.
2. Identify/confirm the correct payer order for possible Medicare overpayments.
3. Promptly complete an unsolicited/voluntary refund request to Medicare for erroneous payments.
4. Establish or verify that there are internal processes (manual or automated overpayment checks such as system edits) to prevent future errors. This needs to be done to ensure Medicare is not billed for medical items and services that are authorized and the responsibility of the VA (or any other insurer).
5. Initiate or continue ongoing monitoring to identify and promptly address duplicate payments. You can track overpayment recovery efforts using a manual follow-up log or system entries to automate and standardize workflow processes.
6. Complete ongoing risk analysis to determine areas of high risk related to duplicate billing errors.
7. Train/retrain staff as needed regarding Medicare Secondary Payer (MSP) inquiries and proper payer order identification.

Good to know: To help you determine the correct payer order the Medicare Learning Network (MLN)  and fact sheets have more information on Medicare Secondary Payer requirements. And, for all the specific MSP rules and special admission and claims processing procedures for providers, suppliers, FIs, and carriers, refer to the .

Institutional Providers Should Note This Advice

Institutional providers can follow these best practices:

1. Update patient insurance profiles at each visit. Review or administer the MSP questions each time you treat or admit the patient.

Ensure the update includes MSP information before providing services. Include employer-sponsored group health plan (GHP) information or info on non-group health plan (NGHP) coverage resulting from an injury or illness (i.e., a liability insurer, no-fault insurer, or workers鈥� compensation entity, etc.)

2. Include patient responses to MSP questions and eligibility verification in the HIPAA Eligibility Transaction System (HETS) Health Care Eligibility Benefit Inquiry and Response System.

Context: The HETS allows providers or their authorized agents to obtain beneficiary eligibility data for the purpose of preparing an accurate Medicare claim, determining beneficiary liability, or determining eligibility for specific services.

: 鈥淭he Health Care Eligibility Benefit Inquiry and Response Implementation Guide and the National Electronic Data Interchange Transaction Set Implementation Guide provide the standards that must be followed when using 270 and 271 Transaction Sets. The 270 Transaction Set is used to transmit health care eligibility benefit inquiries from health care providers, insurers, clearinghouses and other health care adjudication processors. The 270 Transaction Set can be used to make an inquiry about the Medicare eligibility of an individual. The 271 Transaction Set is the appropriate response mechanism for health care eligibility benefit inquiries.鈥�

Tip: If the system doesn鈥檛 identify any errors in the data, the 271 response transaction is returned with the Medicare beneficiary eligibility data within that 271 response. Check MSP effective dates and end dates. If the MSP record is still open, a begin date will appear but an end date won鈥檛.

3. Identify all known primary payers to Medicare on the claim.
4. Submit claims to the appropriate primary payer first.
5. Submit MSP information to the Medicare administrative contractor (MAC) using proper claim condition, occurrence, and value codes (for providers using form CMS-1450 or its electronic equivalent).
6. Submit to the MAC an explanation of benefits (EOB) or remittance advice (RA) from any other insurers with all appropriate MSP information on the hard copy claim; or, provide the necessary information in the appropriate fields, loops, and segments required to process an 837I electronic MSP claim.
7. Provide updated information to government agencies as appropriate.

Check Out These Suggestions for Part B Providers

Part B providers (physicians, practitioners, & suppliers) should consider this advice:

1. Gather accurate MSP data each time you see or provide an item or service to the patient.
   Determine if Medicare is the primary payer by asking patients or their representative for MSP details.
2. Bill the primary payer before billing Medicare.
3. Submit an EOB or RA from the primary payer with all MSP information correctly listed on the hard copy claim.If submitting an electronic claim, include the necessary information in the appropriate fields, loops, and segments required to process an 837P electronic claim.
4. Provide updated information to government agencies as appropriate.

Important: Providers must keep responses to completed MSP questions and other MSP details for 10 years after the service date. Keep hard copies or store the information electronically. Maintain negative and positive question responses. Once you collect information about other patient payers, be certain they appear on the claim.

Patricia Zubritzky, BS, CRCE-I, Contributing Writer, Pittsburgh