Panic. Frustration. Fear. A Medicare beneficiary feels these emotions, and more, whenever their provider gives them the bad news. “Medicare is denying coverage for this treatment.” There’s nothing worse than hearing that after a lifetime of paying into the Medicare program your important medical care won’t be covered.

Should this happen? The short answer is no, this should never happen. Medicare is a secondary payer to other forms of insurance, but it’s a payer. If other insurance isn’t contractually or legally responsible to pay for treatment, Medicare is required to pay.

But providers often completely misunderstand payment rules and direct the beneficiary to call Medicare to straighten it out. The Medicare call center in turn directs the beneficiary to call the workers compensation or no fault claims payer with the instruction to “terminate ORM,” often when Medicare’s own policies forbid ORM termination.

To resolve this painfully frustrating back-and-forth, the agency has issued yet another MLN Matters alert for providers. The blunt title tells the story to providers: Don’t Deny Services & Bill Correctly. While there are no substantive policy changes announced, the tenor and tone of the alert is clear – providers are not permitted to deny medical care to beneficiaries.

CMS directs providers that “If Medicare eligibility shows open Medicare Secondary Payer (MSP) records, don’t deny Medicare patients medical services, treatment, or entry to skilled nursing facilities or hospitals. Continue to see and treat patients, even if we previously mistakenly denied or rejected a claim you submitted as Medicare primary.” CMS further reminds providers “Don’t contact the Benefits Coordination & Recovery Center (BCRC) MSP Contractor to create or update MSP records.”

So, what is the procedure that providers are supposed to follow if they believe that there’s an open workers compensation or no fault claim on file and the ICD codes align for the beneficiary’s care?

1. Bill the NGHP insurer on record. This could be workers compensation or no fault.
2. The NGHP insurer may deny the claim. When that happens, the provider should just bill Medicare and Medicare will pay the claim.
3. If Medicare mistakenly denies the claim, the provider should appeal to the applicable Medicare Administrative Contractor.

The article provides additional information about billing when the beneficiary has a Medicare Set-Aside. CMS basic guidance is that the provider should bill the beneficiary directly when there’s a Medicare Set-Aside on file. Interestingly, CMS’ guidance on MSAs omits any reference to ICD codes. We are concerned that, over time, providers and beneficiaries will be confused about which treatment should be paid for out of a beneficiary’s MSA.

The bottom line on this? CMS has provided the roadmap for providers, but that won’t stop the phone calls from coming into workers comp and no fault insurers and TPAs. We have a four step process that insurers and TPA should follow whenever faced with these phone calls. Here’s what to do when a beneficiary or their family member are on the line:

1. Confirm that the provider has not yet treated the patient and/or has refused to bill Medicare. The provider must not deny care to the patient.
2. The patient or family member should notify the provider that they are not permitted to deny treatment. Provide the patient or family member with the MLN Matters article if warranted.
3. This should resolve the issue! The beneficiary should receive medical care.
4. If, upon reviewing the Section 111 reporting history you identify that ORM should be terminated, terminate ORM. If ORM is technically open, no further action is required.

We know that this won’t solve all of these issues, but it should solve most of them. And it won’t stop the phone calls from coming in. Until providers come to their senses and familiarize themselves with how to follow these instructions, the phone calls will keep coming. Let’s hope that CMS’ blunt reminder that providers should not deny services will penetrate.

If you have issues with wrongfully denied services, we can help. Contact ECS’ Medicare compliance experts at mspcompliance@examworkscompliance.com or email Marty Cassavoy at martin.cassavoy@examworkscompliance.com.