Medical Coding and Billing: Medicare Supplement Policies - dummies

Medical Coding and Billing: Medicare Supplement Policies

Medicare supplement policies cover the charges that Medicare doesn’t pay, so it is important to know if a patient has supplemental policies for medical coding purposes. Normally, Medicare pays 80 percent of allowed expenses after the participants meet the annual deductible. Many patients enroll in secondary coverage to make up the difference.

These plans may cover the annual Medicare deductible and the 20 percent co-insurance left over by Medicare. These supplements don’t cover expenses that Medicare doesn’t approve, however.

A true Medicare supplement serves as a gap coverage to pay what Medicare approves but doesn’t pay. Medicare patients do not usually benefit by carrying a second major medical plan, and they are surprised when faced with unplanned medical expenses.

Your best bet is to verify secondary coverage in addition to Medicare eligibility prior to any patient encounter. The question you need to ask as a coder is “Does this secondary plan cover what Medicare approves but does not pay?”

Some Medicare supplement policies accept claims directly from Medicare, a practice known as cross-over claim submission. Patients with these plans need to let Medicare know that they have a Medicare supplement plan, the details of that plan, and the effective date. Then, after Medicare processes a claim, it sends the claim directly to the secondary payer, and the provider is paid in a more timely fashion.

Some other supplemental Medicare carriers claims will cross over, but they are not automatic. These are known as Medigap policies. To get Medigap policies to cross over, a provider needs to enter the policy holder, policy number, and name of the plan on the HCFA-1500 or UB-04 along with the carrier’s assigned Medigap number.

Secondary complementary claims or Medigap claims don’t automatically cross over to the secondary carrier if the claim is totally denied, a duplicate claim, an adjustment claim, a claim that has been reimbursed by Medicare at 100 percent, a claim that is submitted to Medicare outside the eligibility dates, or a claim for a provider who doesn’t participate with Medicare.

When the cross-over action is automatic, you don’t have a chance to correct an error on a claim.