Author Topic: Medicare overpaying on MSP claim  (Read 1363 times)

MBiller

  • Newbie
  • *
  • Posts: 6
Medicare overpaying on MSP claim
« on: December 30, 2014, 10:55:16 AM »
Medicare seems to be overpaying on our MSP claims when the primary payer has a per diem contract.

Example:  We have a $80 flat rate for a particular payer we are contracted with.  That payer applies the full $80 to the first line item on the claim and then has a zero allowable for all other line items.  They may pay $45 and then say the patient has a $35 copay on that first line item. We bill Medicare secondary for the $35 copay and Medicare pays on all lines items where the primary payer had a zero allowable so Medicare ends up paying more than the $35 balance.

Any ideas on how we can get Medicare to process these to only pay the remaining patient balance?  Medicare states they are paying correct, but from everything I'm finding, they aren't.  They are also then applying patient 20% responsibilty amounts to those line items where the patient had no responsibility from the primary.

We are entering the COB info on the electronic claim showing that those other line items are 100% contractual adjustments with no patient responsbility.   

PMRNC

  • Hero Member
  • *****
  • Posts: 4235
    • One Stop Resources & Networking for Medical Billers
Re: Medicare overpaying on MSP claim
« Reply #1 on: December 30, 2014, 11:06:16 AM »
I've seen this but usually it's Medicare primary and patient has individual plan.   Is the primary an individual plan? Could the COB be incorrect? Is this just for one patient or a few different patients different carriers?

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

MBiller

  • Newbie
  • *
  • Posts: 6
Re: Medicare overpaying on MSP claim
« Reply #2 on: December 30, 2014, 12:46:08 PM »
It's happening with multiple patients that have this payer as primary.  We do have another per diem contract with a different payer who takes the daily rate and prorates it across each line of service and those end up being paid correctly from Medicare.  It only seems to be when this payer is primary because they have zero pays on multiple line items and Medicare then pays on those line items when we are contractually obligated with the primary to adjust them off.