Are You Paying Twice?
Each month, health plans receive files and premium reductions for members deemed to have secondary coverage, which the Centers for Medicare & Medicaid Services (CMS) calls Medicare Secondary Payer (MSP). MSP shifts the burden from Medicare to commercial insurance companies. CMS receives information from a multitude of sources identifying beneficiaries who have other coverage appearing to be primary to Medicare. When a member is identified as MSP, CMS reduces the payment for those members to 17.3% of the full premium.
When the MSP record is valid, that premium payment is sufficient for the health plan to pay services on a secondary basis. If the MSP record is obsolete, and the plan is paying on a primary basis, the plan is paying twice: paying primary for the service and paying through reduced premiums from CMS. This can be a huge premium loss for a health plan of typically around $700 per member per month for every beneficiary incorrectly classified as MSP.
As with all things involving CMS, accuracy is critical.
Reviewing each MSP-identified individual and validating the information is the only way to ensure the member is set up correctly and the premium and claims payments are accurate. MSP validation is not a one-and-done process―information can change, be inaccurate, or be out of date. Outreach validation requires diligence and persistence. Electronic Correspondence Referral System (ECRS) submissions need to be monitored for non-responses and records under development. Other coverage information and system flags need to be updated for claims reprocessing and recoveries from other insurers for claims paid as primary in error.
Do you know the status of each of your MSP members? Are you revalidating information on a regular basis? Are you sure you are not paying twice? If you aren’t sure, Gorman Health Group (GHG) has delivered exceptional outcomes for our clients by recouping millions of dollars in MSP recoveries. We can help you evaluate your process and your existing MSP records to ensure you are only paying once.
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