HCFA focusing attention on benefit claim checks

Company gets $87 million contract

As part of its 2000 waste, fraud, and abuse program, the Health Care Financing Administra tion has awarded its first national contract to an outside vender to ensure Medicare does not pay health care claims that are the responsibility of private insurance companies. HCFA’s new national coordination of benefits (COB) contractor will be Group Health Inc. in New York City.

"Medicare dollars must be spent on legitimate services for elderly and disabled Americans, not to pick up the tab for other insurance companies," HCFA administrator Nancy-Ann DeParle explained when announcing the contract.

Under the arrangement, Group Health will coordinate Medicare payments with other insurance companies by collecting, managing, and reporting claims information. The total cost of the contract will be $87 million over five years.

For those unfamiliar with the rules regarding coordination of benefit payments, here’s a summary provided by HCFA:

• Patients age 65 or older covered under an employer’s group plan based on their, or their spouse’s, current employment must use those benefits. The same applies for people who have Medicare based on a disability and who are covered under the plan of an employer of 100 or more employees (or a multiple employer plan that includes an employer of 100 or more employees).

The ESRD exception

In such cases, Medicare only pays for benefits not covered by the employer’s group plan. How ever, there is an exception for patients with end-stage renal disease (ESRD).

• Seniors who have or who develop ESRD and are covered under an employer group plan must use those benefits for the first 30 months after becoming eligible for Medicare based on ESRD. Medicare then becomes the primary payer. How ever, if the employer’s coverage was secondary to Medicare when the patient developed ESRD, Medicare continues to be the primary payer.

If any no-fault liability insurance or payment from a liable third party is available, then the benefits under that plan (or from that liable third party) must be applied to the costs of health care covered by Medicare.

Where Medicare has provided benefits and a judgment or settlement is made with a no fault or liability insurer (or liable third party), it must be repaid.