CMS is Coming! CMS is Coming!…Are You Ready?

1. CMS is Coming! CMS is Coming!…Are You Ready?

2. 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.

3. Objectives At the end of this session: • 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.

4. Why is an Audit Necessary? • Is the hospital billing correctly? • 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.

5. Why is Audit Necessary • Is the hospital compliant with the regulation • Is the MSPQ completed • Is it completed correctly

6. What is Necessary for an Audit? • Patient Records • Any and all records requested by auditors for review. • The auditors will be looking for documentation of the MSPQ • Patient Billing Records • 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)

7. Lessons Learned • You will be interviewed by the auditor • If they have questions the auditor will be asking you. • Know your procedures and policies • Know your ADT registration system

8. 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

9. Frequently Asked Questions • How often is the hospital required to complete MSPQ? • Inpatient • Every inpatient admission • Outpatient • 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

10. 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.

11. 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.

12. 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.

13. 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.

14. QUESTIONS

15. 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

16. References • 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