REIMBURSEMENT PAGE
By DEVON BERNARD
Secondary Scenarios Tips for billing correctly when Medicare is the secondary payor
Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 18 to take the Reimbursement Page quiz. Receive a score of at least 80%, and AOPA will transmit the information to the certifying boards.
E! QU IZ M EARN
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BUSINESS CE
CREDITS P.18
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OME OF THE MORE confusing
billing scenarios are those involving multiple payors. When there is more than one payor, questions arise regarding who needs to be billed first, how much each payor will pay, and what happens if the primary payor fails to pay a claim. Fortunately, when one of the payors involved is Medicare, the answers to those questions can be easily found by examining the Medicare as Secondary Payor (MSP) provisions and regulations. Several MSP scenarios always render Medicare the secondary payor, meaning that the patient’s other insurance must be billed, and an explanation of benefits acquired, before you may bill Medicare. These situations involve the working aged, workers’ compensation, no-fault and liability insurance, end-stage renal disease (ESRD), and disabled beneficiaries. This month’s Reimbursement Page examines each of these situations and offers insight into how each program operates, as well as how each program affects Medicare’s payment status.
Working Aged
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FEBRUARY 2022 | O&P ALMANAC
PHOTO: Adobe Stock
The most common scenario that makes Medicare the secondary payor is the MSP Working Aged program. Individuals involved in this program have become entitled to Medicare benefits, based on age, but have not yet retired. For
patients to be considered working aged, they must be at least 65 years old and enrolled in their employer’s group health plan (EGHP); the employer must have at least 20 employees. The EGHP also may cover the patient’s spouse, who would be considered working aged, even if they are currently retired. For the purpose of the MSP Working Aged provision, a “spouse” is defined as “a person whose marriage is valid in the jurisdiction in which it was performed, including one of the 50 states, the District of Columbia, or a U.S. territory, or a foreign country, so long as that marriage would also be recognized by a U.S. jurisdiction.” In addition, any time an employer, insurer, third-party administrator, group health plan, etc., has a more inclusive definition of spouse, it may assume primary payment responsibility for the individual in question; and if the individual is reported as a spouse, Medicare will pay accordingly. Keep in mind that if the patient has a retirement plan through their employer and they are 65 or older, the retirement plan will always be secondary to Medicare. In addition, if the patient chooses not to be covered by the EGHP and wants Medicare as their primary insurer, they cannot also receive benefits from the EGHP; it may only be one or the other.
