MEDICARE SECONDARY PAYER
AUDITS
October 12, 2012
St. Joseph’s Hospital, Tampa Florida
AAHAM - FAHAM - HFMA Workshop
Marty Lassiter, B.A. CPAM
Claire Lester, B.A. CPAM
History of Medicare Secondary Payer
Regulations
• In the beginning, Medicare providers billed Medicare first for
all services rendered to Medicare beneficiaries.
• In 1980, the Omnibus Budget Reconciliation Act established
Medicare as Secondary payer in Auto Accidents and Liability
cases. Additional federal laws modified the Medicare
secondary payer regulations even further.
• Medicare is only responsible after other primary payers
have made payment. Medicare calculates any additional
amount due from the program.
• Federal Law takes precedence over State law and private
contracts.
Medicare-Provider Relationship
• Every health-care facility that receives reimbursement from
Medicare adheres to the Center for Medicare/Medicaid Services
(CMS) regulations.
• The Conditions of Participation (CoP) is the provider contract.
Hospitals and other medical providers agree to follow the CoP
contract regulations.
• These rules are published in the Federal Register, and require
regular inspections to verify regulations are followed consistently.
• Failure to follow CMS regulations can result in Civil and
Monetary penalties. Medicare Secondary Payer is
a focus area for CMS.
Provider Compliance
Training Requirements
•
All CMS Providers must provide compliance training
•
New Hire Training Course -Registration 12 days - CBO 9 Days
– A department course required for all new employees covering
compliance guidance, HIPAA, Medicare Condition of Participation,
Fraud and Abuse, MSP, Three Day Rule, and department policies.
– Computer Based Training, Web resources- forms, policies, Medicare
Information, hyper links to payers, on line training manuals.
– Competency Testing
•
Annual One Day Refresher Training Course
– The annual Medicare compliance training course consists of a review of
the training materials, taken from the New Hire Training sessions, for the
Admitting, Registration and Patient Financial Team members, and any
new regulations.
How CMS Selects Providers For
MSP Audits
Each state has to review 10% of its total hospital
population or 20 hospitals, which ever is less.
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For 2012, Florida has 176 hospitals
10% = 18 hospitals
21 hospitals were reviewed
10 from Miami-Dade and Broward counties
11 selected from Tampa Bay and surrounding
counties
Medicare MSP Review History
• A standard provider review of Hospital Admitting and
Billing practices by the Medicare Administrative
Contractor.
• MSP Audits in the past were done by the First Coast
Service Option’s Jacksonville office. The one hospital
reviewer’s title was Hospital Reviewer, MSP Recovery.
• This department recently expanded and moved to four
new Provider Audit and Reimbursement (PARD) Offices.
There are offices in Jacksonville, Orlando, Miami, and
Tampa.
• The Hospital Reviewer we had is a CPA.
BayCare’s Claim Submission Selection
• Hospital Reviewer selected the Claim
Sample from previous month(s) of paid
claims- minimum of 20 to a max of 60.
• 2/3 were Inpatient Claims-mixture of
bill types; included HMO “No Pay” bills.
• 1/3 were Outpatient Claims-mixture of
bill types.
• Various primary and secondary cases
with Hospice, liability, HMO, etc.
Reality
MSP Audit Timeline
• FCSO Written notice to hospital CFO
• Advises CFO to expect a listing of claims selected and a
letter of instruction, which arrives within 2 weeks with a
deadline to return selected claims.
• FCSO completes claim desk review.
• FCSO then sends next notice to hospital of on-site review.
• On-site review and exit interview followed by written
conclusion of hospital’s compliance with MSP regulations.
BayCare’s MSP Experience
Audit Claim Selection Letter
FCSO Hospital Reviewer requested 40 claims per hospital with
supporting documents:
• UB04
• MSP Admission Questionnaire
• Beneficiary’s Medicare Summary Notice (MSN)
• Admission Policies that identify “Other Payer” primary to
Medicare
• Registration Policies that describe the process and systems
used to meet compliance
• Billing policies that identify “Other Payer” primary to Medicare
and Medicare “No Pay” billing procedures
• Medicare Secondary Payer Training Manuals and policies
MSP Audit Claims and Supporting
Documents Submission Process
• The Hospital Reviewer notice shows a postal date
deadline for receipt of claim selection documents
• Our submission was scanned to a CD
• The Hospital Reviewer had a specific contact to answer
questions (PFS Auditor) on submitted claim
documents
• The Hospital Reviewer sent a list of detailed questions
for further information on individual claims
• The PFS Auditor coordinated all responses which
included copies of insurance verification, insurance
cards copies, and some account history notes.
• More detail was provided in the 2012 reviews
BayCare’s Internal Preparation
– Informed Management of pending review
– Dispersed FCSO letters to all related departments
– Assigned a point person for audit coordination- PFS
Auditor
– Established an MSP Review Committee composed of
Billing, Registration and Audit Team. Weekly
teleconferences scheduled to keep all informed.
– Assigned teams to gather requested documentation.
– PFS Auditor coordinated assembling audit material.
– Teams reviewed all related policies & training material.
– Scheduled in-services with Billing and Registration.
– PFS Audit and Managers reviewed signage, brochures,
and team delivery of required materials & explanation of
forms being signed during admission interviews.
Submission to FCSO Reviewer
• Check and recheck the documents for
correct name and admission date.
• Verify all required material is gathered
and questions regarding supporting
documents were clarified.
• Once the claim submission was
validated, we made a file copy of the
documents.
• We supplied all requested information to
the FCSO reviewer.
• The FCSO reviewers established a cordial
and helpful relationship.
Team Preparation
• Team members are trained on interview and mentally prepared.
When not sure on a response, check with management, or review
the policy.
• The Hospital Reviewer uses standard questions from the Manual.
• Golden Rule- only answer the questions asked in simple terms. If
it requires only a yes or no answer - that is enough. Think before
you answer, ask for clarification if unsure, and speak slowly.
• Be prepared to defend any claims that might be outside the
standard procedures.
• We had an LCD projector to show the on-line Patient Accounts
systems available and how our verification system software
detected the primary payer on preselected claims.
Receipt of Facility Notice Letter
• This letter acknowledges receipt by Hospital
Reviewer of requested documentation.
• Shows an on-site review date & approximate
time line.
• The letter asks if the meeting facility will be
different from facility address- if so, supply
correct address.
• Requires that Registration and Billing staff be
present for interview and mentions a patient
registration observation will be done.
BayCare’s Site Review
• Hospital Reviewer sent meeting agenda in advance.
• Hospital team appointed a point person (welcome) from the
hospital and basic information about facility.
• Admitting and Billing people (Managers and Coordinators )
will meet with the reviewers.
• Most questions on the claim sample were covered prior to
the Q & A by Hospital Reviewer with PFS Auditor.
• Billing interviews were independent of Admitting interviews.
• A copy of the Medicare Quarterly Credit Balance 838 was
requested either in advance or at interview.
• Direct Observation completed of a Medicare registration.
• Closing statements and exit conference with the group.
Points to Remember
• Anything you discuss with Hospital Reviewer
should be reviewed in advance for correctness.
• Be truthful, state facts, and don’t give opinions.
• Keep all answers short and to the point.
• Meet all deadlines indicated in the submission
documents.
• Keep copies of all submissions.
• Our reviewer was new and needed to see lots of
detail to verify our processes were thorough.
• Your team members do these functions everyday.
Assessment of Hospital MSP Review
• We were given an unofficial conclusion at the exit
conference.
• A formal letter is sent using a format from the MSP
Manual Ch. 5 sec. 70.5.1-70.5.2
• Any adverse findings will have a follow-up action plan and
an action date. Facility will be expected to reply, if followup items are required.
• The Hospital Reviewer will continue follow-up every thirty
days; after three months with no resolution a higher level
of reporting begins (70.4).
• MSP Review information and Flow Sheet provided as a
hand out.
• All hospitals should prepare for the Spring of 2013.
MSP Audits
• Questions or comments??
**************************************************
Marty and Claire are BayCare PFS auditors for the inpatient and
outpatient Registration and the Central Business Office for all
BayCare hospitals. They conduct policy/procedure/compliance
auditing and monitoring, and assist with team member training.
• marty.lassiter@baycare.org
• claire.lester@baycare.org
• Paul Tucker (Uncle Sam) volunteer