Question

Exercise 14.1 - Medicare as Secondary Payer

Review the following cases and determine the CMS- prescribed billing order for each.

EXAMPLE: Patient is retired and covered by Medicare, an employer-sponsored retirement plan, and his spouse's employer-sponsored large group plan.

Billing Order: Employer- sponsored large group plan, Medicare, employer-sponsored retirement plan.

1. The patient is the policyholder in an employer-sponsored large group plan and has Medicare, a Medigap policy, and a $100-per-day extra coverage hospital plan.

Billing Order:

2. The patient has Medicare and an employer-sponsored retirement plan, and the patient is a dependent on the spouse's employer-sponsored large group plan. The claim is for an injury received in a car accident.

Billing Order:

3. The patient has a retirement plan through his former employer, Medicare, and a cancer policy. The patient is diagnosed with cancer. The spouse is deceased.

Billing Order:

4. The patient is 67, working full-time, and covered by Medicare, an employer-sponsored large group plan, and a Medigap plan. The spouse is retired, 62, and covered by an employer-sponsored plan for 18 employees.

Billing Order:

5. The patient is 50 and disabled and has Medicare and an employer-sponsored group health plan that covers 50 employees.

Billing Order:

Answer 1

1. Billing order would be - Employer-sponsored large group plan, Medicare, Medigap, $100-per-day extra coverage hospital plan (Medicare is secondary when a person has EGHP of more than 20 emplyoyees and here it is a large group plan indicating more than 100 emplyoees. Medigaps covers what is not covered under medicare. And a $100-per-day extra coverage hospital plan is a supplemental insurance plan which pays the cost that are not covered under other plans)

2. Billing order would be - Spouse's employer-sponsored large group plan, Medicare and Employer-sponsored retirement plan. (Spouse's plan pays first and Medicare pays second if the patient is retired and covered by his spouse’s group health plan coverage, Medicare pays prior to Employer-sponsored retirement plan)

3.  Billing order would be - Cancer policy, Medicare, Retirement plan (Medicare acts as a secondary payer when a patient has third party liability policy for treating a condition that comes under that policy i.e. cancer)

4. Billing Order: Medicare, Medigap, Group health plan (since the patient is older than 65 and he is still working and the company has plan for less than 20 emplyoees)

5. Billing order: Medicare , Group health plan (Since patient is less than 65 years old, disabled and most importantly the company has less than 100 employess covered under the plan)