MSP accuracy must be at 98%

Patients might tell a registrar that they still have a Medicare Advantage plan when they no longer do, that they do not have supplement A & B coverage when they actually do, or that they have Medicare for disability coverage when it is really for end stage renal disease.

“We used to have many challenges with getting accurate information on the claim,” says Kym Brown, CHAM, patient access manager at Saint Elizabeth Regional Medical Center in Lincoln, NE.

Patients weren’t always knowledgeable of what their coverage was, says Brown. “Medicare requires accuracy. When the correct reason for, or the dates of entitlement are not correct, the claim is denied,” she says.

A dedicated FTE at Saint Elizabeth Regional now audits Medicare Secondary Payer (MSP) status for all Medicare accounts, using online tools to verify Medicare entitlement. “We were able to justify the FTE because quality and denials management are a priority at our organization,” says Brown. “It was immediately cost-effective. Our incomplete claims and denials are greatly reduced by having a watchful eye on the MSP.” She estimates that denials and incomplete claims have been reduced by 75% to 80%.

The MSP auditor is able to make sure all of that information is correct before it is billed, adds Brown. Here is what the department’s Medicare MSP auditor does:

The MSP auditor is located in the main registration area, is an onsite resource for patients, and also is available by phone and email to the decentralized registration areas.

• The MSP auditor ensures the claim is accurate.

Some patients are unaware of being in a Medicare A bed status, for instance. “The auditor calls around to find if patients are in a Medicare A bed and irons out the wrinkles in the MSP,” says Brown.

If a patient is occupying a Medicare A bed and comes in for an outpatient procedure, staff members need to make sure that they are billing that facility for their charges, she explains. “Otherwise we could get into a double-dipping scenario, or one of us could be denied,” says Brown.

• She monitors lifetime reserve days, checks for entitlement for all patients over 65 years of age, and works closely with case management.

The facility’s case management team uses the MSP auditor as a resource to investigate the patient’s current Medicare entitlement status, the type of Medicare coverage, whether the patient is in a Medicare Advantage plan, and whether the patient has a Medicare supplement or other commercial insurance that should be primary.

“The MSP auditor also keeps a close eye on lifetime reserve days,” she adds.

• The MSP auditor monitors aging unbilled accounts and helps gather needed information.

“With Medicare, we have a window of time to bill accounts,” says Brown. “If there are accounts sitting in an unbilled status because the MSP is not correct, we can miss those windows of time.”