Medicare Secondary Payer - Auditing And Monitoring Program Page 2

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MEDICARE SECONDARY PAYER – AUDITING AND MONITORING PROGRAM
v. Occurrence codes
w. Financial class codes
x. Financial class change codes
y. Amount billed to Medicare
z. Amount paid by Medicare
aa. Date of payment amount by Medicare
bb. Amount paid by other party, if available
cc. Date of payment amounts by other party, if applicable
dd. Total payments
1. Identify HHS specifications for ICD-9 codes that
Medicare tags for potential Medicare Secondary
Payer claims.
2. Review the Trauma Codes from CMS carrier
manual (section 4305) and ensure that these
codes are also included in the criteria for the
Medicare Secondary Payer Universe.
3. The criteria to establish the Universe for
Medicare Secondary Payer paid claims shall
include the ICD-9 codes Indicating Accident,
Illness or Injury
2. Import the file (received from IT) for all Medicare Inpatient and
Outpatient paid claims into your data analysis tool.
3. Ensure that the date is formatted as follows MM/DD/YYYY
4. Name the file: All_ClaimsMedicare_date
5. Perform the following analysis
a. Look for gaps in date of service
b. Look for duplicate claims based on identical medical record
number or corporate personal index number, visit number and
name.
c. Also perform a duplicate analysis on all the fields within the file.
d. Run statistics on the paid claims and diagnosis codes
e. Summarize based on the various diagnosis codes
f.
Summarize the paid claim based on Inpatient and Outpatient
claim types.
6. Extract all claims with payments made by Medicare.
7. Perform a JOIN and perform a MATCH analysis based on all the codes
listed under step 4 above
8. Name the universe file: MSP_Universe
9. Document the procedures in a work paper, including any action plan or
follow up item.
10. Document findings onto a Findings & Recommendation Sheet.
MSP – Probe Sample Selection
W/P Ref
Initial & Date
Objective: To select a probe sample of 15 Medicare In patient claims
and 15 Medicare Outpatient claims from the established universe of
Medicare Secondary Payer.
1. Using your data analysis tool, extract the Medicare Inpatient claims
from the MSP_Universe file.
2. Name the file Medicare_Inpatient
3. Using your data analysis tool, extract the Medicare Outpatient claims
from the MSP Universe
4. Name the file Medicare_Outpatient
5. In your data analysis tool , randomly select Inpatient records and
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