Medicare is primary, but claim still denied?
Sometimes an insurance verification system says a patient’s Medicare coverage is secondary, but patient access staff members know otherwise. Rita Ascencio, insurance manager at Lourdes Health System in Camden, NJ, doesn’t just ask patients to go home and straighten it out with Medicare. Ascencio makes the call for them and asks the patient to resolve the matter right away.
"By dialing the number and handing them the phone, we know for sure that they are letting Medicare know," she explains. "Only the patient can do that. And if something comes up in the conversation that the patient needs help with, we can become involved."
In some cases, Auto is still listed as the primary payer due to a car accident the patient had many years earlier. In other cases, the patient’s spouse was still working when the patient became Medicare-eligible, and the spouse’s coverage is still listed as the primary.
These Coordination of Benefits (COB) issues are the number one reason for claims denials at Lourdes. "A lot of that is between Medicare and Blue Cross, because they do a lot of finger pointing," says Ascencio. "Each payer says the other is the primary."
One problem is that Blue Cross requires that each subscriber complete a COB form once a year, asking about other coverage. If the patient has not completed the form, the claim will automatically be denied for COB by Blue Cross, even though Blue Cross is actually the patient’s primary.
To stop these denials, staff members now ask every patient with Blue Cross to complete the form, and it’s faxed to Blue Cross directly. Associates scan a copy of the form into the document management system, so if the billing office gets a denial for COB, they can just pull it up, print it, and mail it in with the claim.
The form needs to be signed by the subscriber, however, and that individual isn’t always there to do so. "We make it as easy as we can. We give them an envelope to mail it in," Ascencio says.
Notation in system
Joan Braveman, corporate director of patient access, estimates that about 700 denials occurred in Lourdes’ three emergency departments (EDs) in the previous six months, comprising 50% of all claims denials.
"Where we have the biggest issue is the ED: Sometimes you just don’t have the time to be as thorough as needed," says Braveman.
If registrars know that an ED patient’s Medicare is the primary, they put a note in the system stating, "This is definitely a Medicare primary. The patient’s pneumonia has nothing to do with the broken arm he sustained in the auto accident."
The lead registrar in the ED reviews accounts to see if any denials involving Medicare can be avoided. "We see if there is any opportunity to clean up the account," says Braveman. "We have a bill hold of four days. So anything we do before then, other than causing rework on our part, is no harm, no foul.’"