CMS Addresses Denial of Medicare Coverage with Providers

MMSEA Section 111 reporting has improved the transparency of claims to CMS and resulted in the denial of coverage to an increasing number of Medicare beneficiaries.  Denial of coverage can be very frustrating to a Medicare beneficiary, as it may be unclear how to address/appeal the denial.  Additionally, insurance carriers, employers, or third-party administrators may be contacted by Medicare beneficiaries who have been denied coverage in order to obtain assistance.

CMS has been addressing the issue of inappropriate denial of Medicare benefits through education and outreach to providers and contractors.  CMS recently issued an article providing specific guidance for correct claims submission when secondary payers are involved.  The article was intended for providers, suppliers, and physicians who bill Medicare and its contractors for services provided to Medicare beneficiaries. 

CMS advises that a properly filed claim prevents Medicare contractors from inappropriately denying claims and expedites the payment process.  To ensure accurate claim submission and timely payment providers, physicians and other suppliers should do the following:

  • Collect full beneficiary health insurance information upon each visit or admission (CMS published a hospital admissions questionnaire which may be used by all providers/suppliers as a guide to collect information from beneficiaries) 
  • Identify the primary payer prior to submission of a claim and bill the appropriate responsible payer for related services
  • Use specific and correct diagnosis codes, especially for accident related claims

If another insurer is identified as the primary payer (NGHP and/or GHP), the provider/supplier must bill them first, prior to submitting a claim to Medicare.  After receiving remittance advice from the primary payer(s), the provider/supplier can then bill Medicare as the secondary payer, if appropriate.  If a patient is seen for multiple services, each service should be billed separately to the appropriate primary payer.  If the insurer(s) deny the claim, Medicare can then be billed along with the reason for the denial found on the primary payer’s remittance (provider does not have to wait 120 days if they have followed this process).

Additionally, the RRE should also do their part to assure proper reporting of claims information, especially ICD-9 diagnosis codes, to Medicare.  CMS stated during the April 24, 2012 NGHP MMSEA Section 111 teleconference that RREs should assure they are using the most accurate and descriptive ICD-9 codes possible in order to assure proper coordination of benefits. 

The coordination of benefits process has many facets and, at times, can be a somewhat cumbersome and complex system to navigate.  In addition to this alert, CMS distributed a technical direction letter to all contractors responsible for processing payment.  The anticipated outcome of this concerted education initiative from CMS regarding appropriate billing practices is a decline in the erroneous denial of Medicare benefits.  In the meantime, the Medicare beneficiary can pursue the appeals process if they feel that Medicare improperly denied coverage.  For additional information on denial of benefits and the Medicare appeals process see our blogs dated August 5, 2011 and November 22, 2011.

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