Practice Management Alert

 When dealing with crossover claims, practices often confuse Medicare secondary insurers with Medigap insurers, says Pamela Sharkey, CPC, CMM, administrator of Medibilling, a company that provides centralized billing for individual doctors and physician groups in Paramus, N.J.
  
Medigap is a private insurance designed to pay for the patient's cost-sharing items under Medicare and to fill in the gaps for items Medicare does not cover. This supplemental insurance is standardized into 10 types of policies and is regulated by the federal and state governments. Medigap claims transfer from Medicare to the insurance companies that provide those policies. To coordinate the benefits of the two insurance plans, namely Medicare and the secondary insurance, Medicare carriers offer "complementary crossover," an arrangement carriers have with insurers to forward Medicare claims to the secondary plan.
  
When Medigap claims transfer, only the claim information from Medicare participating providers is transferred. When secondary claims crossover, Medicare claims' data from both participating and nonparticipating providers are transferred to the secondary insurer. The Medigap transfer and the secondary crossover have different data requirements. The Medigap transfer is controlled by information on the claim form and depends on the Medicare participation status of the provider. Items 9 A-D on the HCFA 1500 claim form must be completed for a Medigap claim transfer.
  
Practices often make the mistake of filling in items 9 A-D on the HCFA 1500 claim form for a secondary insurer, which confuses the crossover process. Those line items are for Medigap insurance only, not secondaries. Carriers vary on their data requirements, so check with your carrier about what information they want and don't want on the claim form when secondary insurance is involved.

  
Each secondary carrier can specify criteria related to the claims it wants to cross over, which excludes some types of claims from the crossover process. Examples of the types of claims secondary insurers often exclude from crossover are those that are:

  

reimbursed at 100 percent
  

for services the secondary does not cover
  

for services provided outside of the plan's effective date and ending date
  

denied as duplicates
  

denied for missing information
  

for services applied to the deductible.

Causes of Crossover Problems

When Medicare crossover does not work, it may be caused by common problems:

  

The Medicare patient's secondary insurer does not have a contractual arrangement for crossover with the Medicare carrier.

  

The Medicare patient's secondary insurer is on the carrier's list of participating crossover companies, but crossover is not set up for the patient's plan or policy.

  

Crossover is in place for the Medicare patient, but an error occurs when the secondary's eligibility file is run against the Medicare carrier's paid-claims file. A secondary insurer may omit a Medicare beneficiary from its crossover eligibility file, or the health insurance claim number may be incorrect and not match with the claim in the Medicare carrier's payment file. Such errors often delete crossover for the particular patient. Many Medicare carriers specifically tell providers that they are unable to make corrections and resend claims to the secondary insurer.

  

The Medicare EOB states claims are crossing over, but they are not, or they are crossing over to the wrong secondary insurer.
  
If a Medicare patient has secondary insurance and the company is on the Medicare carrier's list of participating crossover insurance companies but claims are not crossing over, the patient not the provider must contact the secondary insurer to correct the problem, says Adrienne Rabinowitz, CPC, billing manager of Western Monmouth Orthopedic Associates in Freehold, N.J. The same applies to other crossover problems.
  
If crossover isn't working, or you doubt whether your Medicare claims are automatically crossing over to secondary insurers as stated on the EOB, manually file the secondary claim immediately after receiving the EOB from Medicare, Sharkey advises. "If you let these build up, it will become overwhelming. With many secondaries, you're often dealing with $100 or less per claim, but those can add up fast." Print a hard copy of the claim form from your computer system, attach the EOB from Medicare with the appropriate patient and services highlighted, and mail it to the secondary insurer.
  
If problems persist, ask the Medicare carrier how its crossover program works with the particular insurer and give an example of a claim that did not cross over. You may learn the cause of your problem, and obtain advice on how to correct it, Rabinowitz adds.
  
If the patient still refuses to pay, consider turning the account over to a collection agency.
  
Note: For more information on this subject, see page 12 of the September 2001 issue of Medical Office Billing and Collections Alert.