CMS is Coming! CMS is
Coming!…Are You
Ready?
Introduction

So you think you are ready for an audit…maybe,
maybe not. This presentation will discuss some
of the lessons learned before, during and after a
CMS audit on the Medicare Secondary Payer
Questionnaire.
Objectives
At the end of this session:
1.
2.
3.
Understand why an audit is necessary
Be able to name a minimum of three things
they will need for the audit
Describe some of the lessons learned and how
can that translate to your hospital.
Why is an Audit Necessary?

Is the hospital billing correctly?
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COB – Coordination of benefits
Is the hospital receiving the correct funding from
the correct insurance company – is Medicare
prime?
Ensure proper payment is received
Ensure taxpayers funds are used for their intended
purpose.
Why is Audit Necessary

Is the hospital compliant with the regulation

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Is the MSPQ completed
Is it completed correctly
What is Necessary for an Audit?

Patient Records
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Patient Billing Records
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Any and all records requested by auditors for review.
The auditors will be looking for documentation of the MSPQ
To review the submission of MSP information using
condition and occurrence codes on the claim.
Learning Modules

They may ask what is your training regarding the MSPQ
(always better to be prepared)
Lessons Learned

You will be interviewed by the auditor
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If they have questions the auditor will be asking
you.
Know your procedures and policies
Know your ADT registration system
Lessons Learned

You may need to defend your processes
Know your hospital’s policies and procedures
regarding completion of MSPQ
 Know the requirements you must fulfill

Know the questionnaire
 Correctly document the answers in an accessible manner
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Frequently Asked Questions

How often is the hospital required to complete MSPQ?

Inpatient
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Outpatient
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Every inpatient admission
Following the initial collection, the MSP information should be
verified once every 90 days
Do I have to complete the MSPQ for a beneficiary who
has enrolled in a Medicare Advantage plan?

No, hospitals are not required to ask the MSP questions or to
collect, maintain or report this information
Frequently Asked Questions

When completing MSPQ, what should the
provider do when the Medicare beneficiary is
unsure of his retirement date?

It is acceptable to use today’s date minus five years if
on Medicare longer than that or the date of
entitlement.
Frequently Asked Questions

The model questionnaire does not include a date
field. Should the date be captured as part of the
MSPQ process?

Yes, hospitals must be able to demonstrate that they
collect MSP information on the correct date.
Acceptable documentation is the last (dated) MSPQ,
either electronic or hard copy.
Frequently Asked Questions

Are providers allowed to collect co-payments
assessed by a primary payer from Medicare
beneficiaries in an MSP case?

No. Medicare providers must not accept from the
beneficiary any co-payment or coinsurance upon
services rendered when the primary payer is an
employer Managed Care Organization (MCO) or any
other type of primary insurance.
Frequently Asked Questions

Does the MSPQ require a signature?


No
When should providers report occurrence code
05 (“other accident”) on an MSP claim?

Occurrence code 05 indicates the date of an accident
not described in codes 01 through 04. This code is
used to report that the provider has developed for
other casualty – related payers.
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QUESTIONS
Presenters
Beverly Cruz, BS, CHAM
Supervisor – Patient Access Department
New York Presbyterian Hospital – Weill Cornell Medical Center
212-585-6778
bcruz@nyp.org
Brenda Sauer, RN, MA, CHAM
Director – Patient Access Department
New York Presbyterian Hospital – Weill Cornell Medical Center
212-746-4630
bsauer@nyp.org
References
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Trailblazers Health Enterprises, “Part A MSP
Audit – Questions and Answers”, January 2011
Centers for Medicaid & Medicare Services,
“Medicare Secondary Payer (MSP) Manual,
Chapter 8, February 2005
Centers for Medicaid & Medicare Services,
“Medicare Secondary Payer Fact Sheet – for
Provider, Physician, and other Supplier Billing
Staff”, May 2010