Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare. See 42 U.S.C. 1395y(b) [section 1862(b) of the Social Security Act], and 42 C.F.R. Part 411, for the applicable statutory and regulatory provisions.
Information for Health Care Providers regarding MSP Situations
Workers’ Compensation (WC) is a primary payer to the Medicare program for Medicare beneficiaries’ work-related illnesses or injuries. If a Medicare beneficiary has WC coverage, health care providers must bill WC first.
If responsibility for the WC claim is in dispute and WC will not pay promptly, the provider, physician, or other supplier may bill Medicare as primary payer. If the item or service is reimbursable under Medicare rules, Medicare may pay conditionally, subject to later recovery if there is a subsequent settlement, judgment, award, or other payment.
The Centers for Medicare & Medicaid Services (CMS) recommends the following for Part A institutional providers (i.e., hospitals):
- Obtain billing information prior to providing services. It is recommended that providers use the CMS questionnaire, or a questionnaire that asks similar types of questions; and
- Submit any MSP information to the intermediary using condition and occurrence codes on the claim.
CMS recommends the following for Part B providers (i.e., physicians and suppliers):
- Follow the proper claim rules to obtain MSP information such as non-group health coverage resulting from an injury or illness;
- Inquire with the beneficiary at the time of the visit if he/she is taking legal action in conjunction with the services performed; and
- Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process an MSP claim.