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Tuesday, June 22, 2010

Denial claim - MEDICARE IS THE SECONDARY PAYER

MEDICARE IS THE SECONDARY PAYER

Description:

The care of a Medicare patient may be covered by another payer through coordination of benefits. Medicare may be the secondary payer in our offices for the following reasons:
* Working aged. The Medicare patient is: 65 years or older, employed full- or part-time by an employer who has 20 or more full- or part-time employees, and covered under the Employer's Group Health Plan (EGHP); or covered under the EGHP of an actively employed, full- or part-time spouse whose employer has 20 or more employees.

Liability and auto/no-fault liability: Section 953 of the Omnibus Budget Reconciliation Act of 1980 was amended by the Deficit Reduction Act of 1994. It precludes Medicare payment for items or services to the extent that payment has been made or can reasonably be expected.

* Where the primary claim should be filed under auto, medical, Personal Injury Protection (PIP), no-fault, worker's compensation, or any liability insurance plan or policy including self-insurance plans.

* Workers' compensation: Medicare will be the secondary payer for work-related illnesses or injuries covered under a workers' compensation plan.

* Veteran's Affairs (VA): VA records are set-up by information received by the Social Security Administration. Veterans who are entitled to Medicare may choose which program will be responsible for payment of services covered by both programs.


Action :

Obtain routine information concerning the working/retirement status of each Medicare patient with each visit. Be sure to stay updated. Contact your Service Provider department about potential conflicts and the appropriate coordination of benefits.

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