Medicare Claims Recovery and COB

Each year, millions of dollars in claims overpayments are made by Health Plans for their Medicare members. We have found that these overpayments are usually made for MA members’ out-of-network claims and for Medicare eligible members not enrolled in a MA Plan.

Claims for MA Members

Since the inception of the Balanced Budget Act of 1997, MA plans have had the opportunity to utilize the Medicare fee schedule for virtually all non-contracted claims. However, the formulae and information necessary to implement this are sometimes difficult to obtain. Most organizations incorrectly pay a significant portion of these claims at 100% of charges. This results in significant overpayments of non-contracted claims. For a 50,000-member plan, for example, annual savings can be as high as $2.5 million.

In addition, there is a subset of MA members for which another primary payor may be responsible for claims payment under the Medicare Secondary Payor (MSP) regulations. The primary payor could be another health plan in the case of MA Working Aged members or Medicare in the case of MA Hospice members.

Claims for other Medicare eligible Members

Typically each Health Plan has a significant number of Medicare eligible members that are not enrolled in their MA plan. Many of these members’ claims should be paid first by Medicare, and not by the Health Plan. However, Health Plans often continue to pay these claims as the primary payer, resulting in significant overpayments.

While some Health Plans have developed procedures for proper Coordination of Benefits (COB) for Medicare members, many plans have not.

MMC 20/20 has developed leading edge technology that empowers health plans to not only identify and recover claims overpayments, but also to avoid future overpayments. Our program consists of the following activities:

  • Evaluating and Identifying Potential Medicare COB Target Members
  • Reviewing Current Medicare COB Procedures
  • Identifying Current Strengths and weaknesses
  • Identifying Members and Services Where the Medicare Carrier or Intermediary Should Have Paid as the Primary Payer, Instead of the Health Plan
  • Assisting the Health Plan in Recovering Inappropriate Payments
  • Developing and Implementing Policies and Procedures
  • Implementing a COB Program that Minimizes Future Overpayments