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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.

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Presentation on theme: "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."— Presentation transcript:

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. 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: 1. Understand why an audit is necessary 2. Be able to name a minimum of three things they will need for the audit 3. 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? Is the hospital billing correctly? COB – Coordination of benefits COB – Coordination of benefits Is the hospital receiving the correct funding from the correct insurance company – is Medicare prime? Is the hospital receiving the correct funding from the correct insurance company – is Medicare prime? Ensure proper payment is received Ensure proper payment is received Ensure taxpayers funds are used for their intended purpose. Ensure taxpayers funds are used for their intended purpose.

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

6 What is Necessary for an Audit? Patient Records Patient Records Any and all records requested by auditors for review. Any and all records requested by auditors for review. The auditors will be looking for documentation of the MSPQ The auditors will be looking for documentation of the MSPQ Patient Billing Records Patient Billing Records To review the submission of MSP information using condition and occurrence codes on the claim. To review the submission of MSP information using condition and occurrence codes on the claim. Learning Modules Learning Modules They may ask what is your training regarding the MSPQ (always better to be prepared) 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 You will be interviewed by the auditor If they have questions the auditor will be asking you. If they have questions the auditor will be asking you. Know your procedures and policies Know your procedures and policies Know your ADT registration system Know your ADT registration system

8 Lessons Learned You may need to defend your processes You may need to defend your processes Know your hospital’s policies and procedures regarding completion of MSPQ Know your hospital’s policies and procedures regarding completion of MSPQ Know the requirements you must fulfill Know the requirements you must fulfill Know the questionnaire Know the questionnaire Correctly document the answers in an accessible manner Correctly document the answers in an accessible manner

9 Frequently Asked Questions How often is the hospital required to complete MSPQ? How often is the hospital required to complete MSPQ? Inpatient Inpatient Every inpatient admission Every inpatient admission Outpatient Outpatient Following the initial collection, the MSP information should be verified once every 90 days 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? 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 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? 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. 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? 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. 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? 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. 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? Does the MSPQ require a signature? No No When should providers report occurrence code 05 (“other accident”) on an MSP claim? 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. 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 QUESTIONS

15 Presenters Beverly Cruz, BS, CHAM Supervisor – Patient Access Department New York Presbyterian Hospital – Weill Cornell Medical Center Brenda Sauer, RN, MA, CHAM Director – Patient Access Department New York Presbyterian Hospital – Weill Cornell Medical Center

16 References Trailblazers Health Enterprises, “Part A MSP Audit – Questions and Answers”, January 2011 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 (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 Centers for Medicaid & Medicare Services, “Medicare Secondary Payer Fact Sheet – for Provider, Physician, and other Supplier Billing Staff”, May 2010


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