How do you handle patients with more than one insurance policy? It can be frustrating to file multiple medical claims for the same patient manually. However, the process becomes much easier if your client is eligible for supplemental Medicare benefits.
This dual eligibility leads to Medicare automatically crossing over your medical claim to Medicaid or other secondary insurers after processing it.
It means you only have to file one claim for your services. But what exactly is a crossover process, and how does it work? Read on to find everything about Medicare crossover claims, including how to bill such claims successfully.
What are Crossover Claims?
Crossover claims, commonly known as Medicare crossover claims, happen when a Medicare insurance holder (a senior citizen) is also eligible for another benefit. In such cases, healthcare providers submit medical claims to Medicare only. After making its portion of the payment, the federal health insurance program automatically transfers these claims to the secondary payer.
In technical terms, crossover is the process through which Medicare transfers processed claim information to Medicaid or other insurance companies. These other secondary insurers typically provide supplemental benefits to Medicare insurance holders.
Hence, you don’t need to bill Medicaid or any other secondary insurance company separately for the remaining amount. Medicare crossover claims not only reduce the administrative burden of the healthcare providers but also minimize the risk of errors and increase the efficiency of the billing process.
How Do Medicare Crossover Claims Work?
Medicare crossover claims follow a systematic process. But before moving on to the explanation, let’s clear some things first. Medicare claim crossovers only occur when Medicare is the primary payer.
So, how do you decide the primary and secondary payers? The answer is simple. You don’t! Healthcare providers can differentiate these companies based on the insurance policies.
Medicare shares payment information with Medicaid and other insurers through the Coordination of Benefits Agreement (COBA). This COBA is a contract between Medicare, the Centers for Medicare and Medicaid Services (CMS), and other insurers.
It allows other benefit programs (offering supplemental Medicare benefits) to share eligibility data with CMS. In return, CMS provides them with Medicare claims information to process secondary benefits. Usually, the Benefits Coordination & Recovery Center (BCRC) oversees the entire crossover process on behalf of CMS.
Here is how Medicare crossover claims work:
Filing Initial Medical Claim
After treating a Medicare beneficiary, a healthcare provider submits a medical claim to the federal health insurance program.
Initial Processing & Payment
Medicare then processes the medical claim. The federal health insurance company determines its portion of the payment (from the patient’s insurance plan) and pays it to the healthcare provider. Since Medicare is the primary payer, it pays a significant amount of the provided service or treatment.
Claim Transmission
Medicare then transfers the processed claim to the secondary payer, usually Medicaid, through the Coordination of Benefits Agreement (COBA). But how do you confirm that Medicare has sent your claim to Medicaid?
The federal health program sends a note with the initial payment notice indicating that it has transferred your claim to Medicaid. This note is usually in the form of a code. For example, Medicare uses Remittance Advice Remark Codes (RARC) MA18 or N89 to indicate that the claim was crossed over.
Supplemental Processing & Payment
After receiving the crossover claim, the secondary insurer processes it and pays the remaining amount. Let’s simplify this with a specific example. The Medicaid program in New York receives processed Medicare claims from BCRC. It simply means that BCRC acts as a bridge between Medicare and Medicaid in New York State.
Example
Let’s consider a real-world example.
- A healthcare provider performs an appendectomy on a senior patient and bills Medicare for $8,350.
- Medicare processes the claim and pays $6,250 according to the patient’s plan.
- After paying its portion, Medicare sends the processed claim to the patient’s secondary payer, Medicaid, in this case.
- Medicaid receives the crossover claim and then covers the remaining amount. In the end, the patient owes nothing to the healthcare provider.
How to Bill Medicare Crossover Claims?
If your patient has another insurance plan besides Medicare, you only need to file the first claim. Medicare will do the rest for you. You can follow these simple steps to file the initial Medicare claim.
Verify Patient’s Dual Insurance Eligibility
Check if your patient is eligible for a supplemental insurance benefit besides Medicare. Go through their insurance plan and make sure that the information is up to date.
Obtain Pre-Authorization
Medicare only covers some treatments or services if they are medically necessary. Therefore, identify such procedures and obtain prior approval to avoid claim denials.
Code the Diagnoses and Treatments
Accurate coding is the key to quick reimbursements from Medicare. Make sure to use the latest and valid diagnosis (ICD-10) and procedure codes (CPT or HCPCS) when filing medical claims.
Submit the Medical Claim to Medicare
The next step is to submit the medical claim to Medicare. Gather all the supporting documents and include correct information about the patient, including ID number, name, and address. Don’t forget to provide all the details about the secondary payer, including the beneficiary ID, so the claim can cross over automatically.
You have two options to submit the claim. You can either submit it electronically via the Medicare Administrative Contractor (MAC) or manually. Individual healthcare providers, like doctors and therapists, can use the CMS-1500 claim form to file manual claims. However, if you work in a hospital, nursing home, or rehabilitation center, use the UB-04 to submit the claim.
What’s Next?
After this, Medicare will process the claim and automatically send your claim to the secondary payer. However, BCRC will reject the crossover claim if there is any error. In that case, you must file the secondary claim manually with a copy of the Remittance Advice (RA) – a document sent by Medicare.
Billing Challenges with Crossover Claims
The crossover claim simplifies the entire billing process. However, the process of crossing over itself is quite complex. Here are some common challenges:
Incorrect or Missing Secondary Payer Information
A lot of the time, the main culprit for issues is incorrect or missing information about the secondary payer. If the beneficiary ID or payer information is missing from the initial claim, BCRC cannot route it to the correct secondary insurer.
To prevent this, you must always check whether the patient has more than one insurance payer. If yes, then ensure to get the details for all of them before providing any services.
Claim Rejections Due to Coding Errors
BCRC will reject a crossover claim if it contains incorrect diagnosis or procedure codes. Even a minor coding mistake can delay your reimbursement significantly.
So, make sure that there are no billing and coding-related mistakes in the claims.
Delayed or Missing Crossover Transmissions
Not every claim crosses over automatically. If you don’t see RARC code MA18 or N89 on your Remittance Advice, Medicare may not have transmitted the claim.
In that case, you must file the secondary claim manually with a copy of the RA.
Auto vs. Manual Crossover Claims
The crossover claims are processed in one of two ways: automatically or manually. Here’s how they are different:
| Auto Crossover | Manual Crossover | |
|---|---|---|
| How it works | Medicare automatically transmits the claim to the secondary payer via BCRC | Provider submits the secondary claim directly with a copy of the RA |
| When it happens | Secondary payer has a COBA agreement with CMS | No COBA agreement exists, or the auto crossover fails |
| Provider effort | Minimal, file one claim and Medicare handles the rest | Higher, additional documentation and submission |
| Risk of errors | Lower, as transmission is system-driven | Higher, as manual entry increases the chance of mistakes |
| Turnaround time | Faster | Slower |
Bottom Line
Medicare crossover claims save healthcare providers from additional work. To summarize, Medicare covers a significant part of its beneficiaries’ treatment. It then automatically crosses over the processed claim to their secondary payer (Medicare and any other private insurance offering supplemental Medicare benefits).
You should submit accurate medical claims with the latest codes to Medicare for a successful crossover. Otherwise, you’ll have to allocate extra time and resources to file secondary claims. Therefore, it is better to outsource medical billing services to avoid such situations.
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