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Medical Necessity/Medicare Secondary Payer
Medical Necessity
HCFA and the Office of the Inspector General (OIG) recognize that physicians and other authorized individuals must be able to order any tests that they believe are appropriate for the treatment or diagnosis of their patients. However, claims submitted for tests or services will only be paid if the service is covered, reasonable, and necessary for an individual patient given his or her clinical condition.
Medicare Secondary Payer
Medicare Secondary Payer refers to those instances in which Medicare does not have the primary responsibility for paying the medical expenses for a Medicare beneficiary.
All providers and practitioners should screen Medicare patients to obtain correct health insurance information before submitting a primary claim to Medicare. Listed below are some questions to ask patients during a confidential screening that will help determine circumstances where Medicare may be the secondary payer:
- Are you currently employed?
- Is your spouse currently employed?
- Are you covered under an employer or union health plan that should be primary to Medicare?
- Did you sustain an injury/illness while at work?
- Are your injuries accident related?
By using the above questions to initially screen your Medicare patients, you will help reduce costs to the Medicare Program as well as administrative costs to your practice.
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Requisitions provided to the laboratory should reflect accurate patient insurance information, including screening for Medicare Secondary Payer. Laboratory employees will provide Medicare Secondary Payer screening when performing phlebotomy on Medicare beneficiaries.
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References
Medicare Part B 1999 Basic Billing Manual.
Medicare B New, Issue 167 Medicare Secondary Payer
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