Medicare Secondary Payer - Auditing And Monitoring Program

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MEDICARE SECONDARY PAYER – AUDITING AND MONITORING PROGRAM
Objective: The objective of the monthly audits are to monitor the Medicare as a Secondary Payer
(MSP) billing function, admitting, billing and medical records to ensure compliance with the Medicare
as a Secondary Payer requirements.
Scope:
All paid Inpatient and Outpatient Medicare claims that meet certain selected codes (ICD-9 and
emergency codes). The current audit period is __________ through ____________.
MSP - Preliminary Procedures
W/P Ref
Initial & Date
1. Obtain and review Medicare Secondary Payer requirements.
2. Obtain and review the “UB-04 Overview for Medicare Part A Provider
Outreach and Education” (presented by Trailblazer and the Center for
Medicare and Medicaid Services) and gain an understanding of the fields
within the UB-04.
3. Research for guidelines/requirements related to completion of the
Medicare Secondary Payer questionnaire (MSPQ).
4. Review your patient account system data elements to determine where
the data is in your system.
5. Meet with the key individuals to gain an understanding of the MSP
accounts and data.
6. Obtain and review your institution’s current policies and procedures
related to MSP.
7. Request access to your patient accounting/billing system as needed.
8. Draft a planning memo with background understanding/explanation that
will be utilized for the background section of the final report.
MSP – Population & Universe Identification
W/P Ref
Initial & Date
Objective: To establish the criteria for identifying the universe of paid
inpatient and outpatient claims for MSP.
1. Submit a request to IT for a data file that includes the following fields:
b. Medical Record Number or Institution identifier
c. Visit/Account Number
d. Last Name
e. First Name
f.
Sex
g. Date of Birth
h. Payer Name (line 50 a through c of the UB-04)
i.
Social Security Number
j.
Admit Date
k. Discharge Date
l.
Patient Process Type ( I, O, E etc)
m. DX1 code (line 66 of the UB-04)
n. DX2 code (line 66 of the UB-04)
o. DX3 code (line 66 of the UB-04)
p. DX4 code (line 66 of the UB-04)
q. Dx5 code (line 66 of the UB-04)
r. Admit DX (line 69 of the UB-04)
s. ECI CODE (line 72 of the UB-04)
t.
Procedure code (line74 a through e of the UB-04)
u. Condition codes
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