MEDICARE SECONDARY PAYER PROVISION-
WORKING AGED IN MISSOURI
JULY, 1986
CONTROL iP-07-86-000 
REGION VII
OFFICE OF ANALYSIS AND
KANSAS CITY, MISSOURI
INSPECTIONS
OFFICE OF INSPECTOR GENERAL
DEPARTMENT OF HEALTH AND
HUMAN SERVICES ................................................................................................................
. . . . . . . . . . . . . . . . . . . . . . . . . .
CONTENTS

Page 
I. EXECUTIVE SUMMY

II. INTRODUCTION

III. SCOPE OF REVIEW 
IV. FINDINGS AND RECOMMENDATIONS

V. TABLE SUMMIZING DOLLAR EFFECT 
OF REPORTED FINDINGS

VI. SUMMRY OF COMMENTS

SOLICITED AND RESPONSES
 EXECUTIVE SUMMARY

The Kansas City Regional Office, Office of Analysis and

Inspections (OAI) conducted a reg ional 
program inspection of
Medicare secondary payer prov is 
ions as they relate to working 
aged under the Tax Equity and Fiscal Responsibility Act of 1982. 
Intermediary data indicated there are 160 short-term hospitals 

Missour i. Our inspection focused on the 30 largest hospitals

since Intermediary data indicated that 73 percent of the working

aged they had identified were in these hospitals. No review for 
working aged was made on the remaining 130 hospitals, where 27

percent of the working aged had been identified by the

Intermediary. 
Four hospitals in Missouri were selected for review 
in conjunc
aged. 
tion with the inspection on working  Blue Cross Hospital
i prepared for our off 
Serv ices, Inc., of Missour  ice a listing of
iciar ies in 
all inpatient benef  these hospitals who were aged
65-69 in 1983-1984. The 
Intermediary identified 3830 benefi
ciaries with 5789 discharges. A randomly selected sample of 
beneficiaries from each hospital were identified. The total of 
300 beneficiaries generated a total of 449 discharges at the four 
hospitals. A total of 11 beneficiaries or their spouses with a 
total of 13 discharges were identified as being working aged 
within the TEFRA definition. 
Comparative data indicated that the four sample hospitals and the

30 hospitals in the universe had similar character istics in func

tional areas reviewed. These four hospitals, therefore, would be

considered representative of the 30 hospitals for purposes of

projecting an overpayment.

Based on our inspection cover 
ing 1983-1984, a projected over
payment of $5, 023, 759 was made by the Medicare program as the
pr imary payer. 
Employer group health plans should have been the
pr imary payer with Medicare being billed as the secondary payer. 
We recommend that the HCFA Reg ional Off ice require the Missour 

Medicare contractors to implement current guidelines according to

Federal regulations, to ensure correct Medicare payments and to

initiate recovery action for all improper payments, retroactive

to January 1, 1983.

Comments were received from HCFA, the Intermediary, and the two

Missouri. 
Carriers servicing Medicare beneficiaries in  These 
comments indicated a general agreement with the findings and 
report. All 
recommendations contained in the  responses
demonstrated a recognition that problems existed during the 
1983-1984 review period. HCFA and the contractors have taken 
steps to implement the recommendations, in whole or in part,
wi thin the limits of budgetary constraints. Acknowledgment was
made that improvement is needed and the responses indicated HCFA 
and the contractors are working to improve procedures for the

identification and processing of claims related to working aged.

-1
 II.	
INTRODUCTION 
This report details the findings and recommendations that

resulted from the program inspection of Medicare Secondary Payer 
provisions--Working Aged in Missouri--conducted by the Office of
Analysis and Inspections, Off 
ice of Inspector General, Kansas
City Regional Office. 
The inspection program was developed and implemented by the

Office of Analysis and Inspections. The inspections are a major

function of OAI as part of its responsibility to minimize the

opportuni ty for fraud, abuse, and waste in DHHS programs.

Specifically, program inspections are reviews which:

(1 )  Examine specific program operations and/or reimbursement 
pOlicies and the manner in which they are implemented to 
determine if they are contributing to fraud, abuse or 
and 
was te , 
(2 )  Demonstrate the significance of the inefficient or inef
fective policy or method of implementation and recommend 
changes which would improve program administration, 
contribute to ensuring proper services are provided to 
dollars. 
eligible beneficiaries and/or save program 
The format of this program inspection report is of an exception
type  in that, only areas requiring improvement are presented. 
No conclusions regarding the overall level of an organization 
' s 
performance should be drawn solely from this report. 
III. 
SCOPE OF REVIEW 
The Tax Equity and Fiscal Responsibility Act of 1982, provided
that Medicare would be the secondary payer in cases where medical 
Plan. 
care can be paid by an Employer Group Health  This would 
affect those beneficiaries or their spouses, who were working,
were aged 65-69 and were a member of a PIan cover 
ing those per
sons. 
Federal Regulations implementing this law were published 

regulations state
42 CFR 405. 340-344 on April 13, 1983. The 
that, effective for services furnished after 1982, Medicare bene
fits (Part A and B) are secondary to benefits payable by an 
employer group health plan for any month in which an individual 
age 65 through 69: 
(1 )	 Is entitled to Part A benefits. 
(2 )	 Is either employed or the spouse is employed and covered
under an employer group heal 
th plan. 
(3 )	 The employer has 20 or more employees. 
-2
 Medicare will be primary payer where: 
(1 )	 not covered under an employer group 
The individual  is
health plan including refusal to accept the employer 
' s
plan. 
(2 )	 Payment is not applicable by an employer group health 
pIan for Medicare covered services. 
( 3)	 Secondary payments will be made to supplement the pri
mary benef 
its paid by the employer group health plan 
that plan pays only a portion of the charge for the ser
ices. 
This program inspection was conducted to determine if HCFA and

its Medicare contractors were correctly identifying Medicare

secondary payer situations. A listing of beneficiaries furnished

by the Intermediary contained 3830 beneficiaries, aged 65 through 
69, having 5789 discharges, who had been inpatients at four 
Missouri hospitals. This listing was used to obtain a randomly 
selected sample of 300 benef ic iar ies, aged 65 through 69, who had
generated 449 discharges. 
Onsite visits were made to four Missouri hospitals to obtain

admission and payment data. In addition, beneficiary history

listings were obtained on the individ als in the sample who had

services billed to Medicare during the review period.

Beneficiary histories were obtained from Blue Cross Hospital

Services, Inc., of Missouri, General American Life Insurance 
City. 
Company and Blue Shield of Kansas  Eleven beneficiaries or 
their spouses generating 13 discharges were identified as working

aged within the definition in TEFRA.

Based on data from the Intermediary there are 160 short term
hospitals in Missouri. 
Intermediary data also indicated that 
percent of the working aged were identified in the 
30 largest

hospi tals. Our inspection involved four of the 30 hospitals

within this group and the projected overpayment 
is based on these

30 hospitals. Although 27 percent of the working aged identified

by the Intermediary were in hospitals under 300 beds, no attempt

was made in this report to project an overpayment to these 
tals. 
smaller hospi 
-3
 IV .  FINDINGS AND RECOMMENDATIONS 
indinq 1

Medicare Paid as Primary Payer for Working Aged

The inspection found that out of 300 beneficiaries generating 449

discharges, aged 65-69, in our sample, 11 beneficiaries having 13

hospital discharges were working or their spouses were working

under employer group health plans. These 13 discharges from the

11 beneficiaries had not been identified by the Intermediary or

hospi tal as working aged before payment had been made.

The 300 beneficiaries represented 449 discharges for the four

sample. 
hospitals in the  The sample of beneficiaries/discharges 
was obtained from a universe of 3830 beneficiaries with 5789

discharges. 
hospi tal 
Comparative data was obtained and analyzed for the four sample 
hospitals and the 30 hospitals in the universe. Functional areas 
reviewed indicated that the sample hospitals and the universe of 
category. 
hospitals compared similarly in every  Therefore, these 
four hospitals would be considered representative of the 
hospitals for purposes of projecting an overpayment. 
Based on the data obtained from the Medicare contractors, a 
Medicare Part A and B overpayment of $40, 855 is calculated for 
services rendered related to these 13 hospi tal discharges.
Projecting the sample to the entire population, aged 
65 through
69, in all 30 hospitals for the review period for whom services 
were billed, overpayments of $5, 023, 759 were made by the Medicare
program. 
Recommenda t ion 
We recommend that HCFA instruct the Medicare contractors indi
cated in this report to review all services provided resulting 
from working aged coverage since January 1983. Applicable reco
very should be made from third party payers or from providers. 
Finding 2

Greater Detection Capability Needed By Intermediary Secondary

Payer Unit

The Intermediary had an established Secondary Payer Unit when the 
program inspection was conducted. The Unit had identified one of 
the beneficiaries as a Medicare secondary payer situation after
payment had been made. 
With respect to this beneficiary, the 
inspection team identified three addi tional periods of hospital 

zation not identified by the Secondary Payer Unit.

-4
 Recommenda t ion 
We recommend that HCFA instruct the Medicare contractors to

establish or improve existing Secondary Payer Units to more

effectively identify Medicare secondary payer situations

invol v ing working aged. 
Finding 3

Improvement Needed By Hospitals in Obtaining Working Aged

Information 
Hospitals are not adequately obtaining critical information 

order to identify working aged beneficiaries or their spouses. 
Def ic ienc ies noted were:

(1 )	 Lack of any information regarding employment status. 
retired. 
(2 )	 Date as to when employee or spouse  This infor
mation would give the validity of the time period 
covered under EGHP. 
( 3 )	 Age of the spouse would have indicated that the spouse
was aged 65 and over and could have quaI if ied as working
aged. 
(4 )	 Information obtained on other insurance or employment 
related insurance forms is not being transferred to the 
billing form submitted to the Intermediary. The

Intermediary is thereby unaware of possible EGHP

cover age. 
Recommenda t ion 
HCFA should ensure that Medicare contractors assist hospitals in

obtaining essential information to identify working aged them

selves or that sufficient information is given Intermediaries to

identify working aged.

Finding 
Lack of Coordination Between Intermediary and Carriers on

Exchange of Information

Intermediary and Carrier guidelines were reviewed to determine 
the extent of coordination for pertinent information on working
aged. 
Review of the contractors records indicates that infor
mation on working aged available to the Intermediary may have 
assisted in preventing payment being made by the Carrier. 
-5
 Recommendation 
HCFA should assure necessary exchange of potential working aged

data among contractors which would prevent overpayments from

being made.

-6
 TABLE SUMMIZ ING DOLLAR EFFECT OF REPORTED FINDING 
Overpayment projection of

Medicare Secondary provision

Medicare  Amount Paid  Projected
Contractor  in Sample  Overpayment 
Blue Cross Hospital 
Inc., 
Serv ice,  of Mo.  $29, 792  $3, 663, 337

General American Life

Insurance Company  600  73, 782

Blue Shield of 
Kansas City  463  286  640

$40, 855  $5, 023, 759

-7
 VI. 
SUMMY OF COMMENTS. 
SOLICITED AND RESPONSES

Commen ts were received from the Health Care Financ ing
Administration as well as the Part A Intermediary and two Part B

Carriers servicing Missouri.

Health Care Financinq Administration

HCFA commented that the recommendations contained in the report 
are appropriate for the review per iod, which was 1983-1984. 
HCFA
indicated the var 
ious steps that have been taken to more effec
tively implement the working aged provisions of the Medicare law. 
This includes: (1) the recovery of funds from known employer 
group health plans, (2) the preparation of a mass mailing to
benef iciaries to obtain MSP information, (3) educational efforts
particularly with hospitals and, (4) preparation of lists of 
beneficiaries covered by EGHP to be shared with Carriers. 
Blue Shield of Kansas City

The Carrier is concentrating its Medicare Secondary Payer activi
, for which it has goals to meet. 
ties on Fiscal Year 1986 The 
expressed reluctance to pursue any pr 
Carr ier  ior MSP/EGHP
si tuations 
because of lack of funding to conduct any necessary
investigations. 
In fact, if the Intermediary were to compile a 
listing of beneficiaries with known EGHP coverage, it would not
be utilized anyway by the Carrier because of a lack of funding to 
investigations. 
conduct the required 
General Amer ican Life Insurance Company

The Carrier commented that the draft report probably gives a 
reasonably accurate picture of the MSP--Working Aged situation 
during the 1983-1984 review period. The Carrier stated that the 
1984 national MSP workshop and the 1985 regional MSP workshop 
thiavees h.a d a significant impact upon improving MSP program activi
The Carrier sees continued improvement in the MSP area 
because of better procedures and periodic workshops, both at the
national and regional levels. 
-8
 Blue Cross Hospital Service, Inc., of Missouri

The Intermediary recognizes the problem that st 
ill exists with 
respect to MSP working aged as evidenced by the large number of
claims being processed by Medicare as pr 
imary rather than as 
secondary payer. The MSP unit is being updated to enable it to 
have automated processing capabilities. 
The Intermediary is planning to use a benef iciary questionnaire 
to detect MSP/EGHP situations dating back to 1983. Also, infor
mation obtained through suspension of claims because of Y-Trailer 
data will be utilized to identify potential MSP working aged
cases. 
The Intermediary is aware of the need for better 
Intermediary/Carrier communication. Lists  iar ies will 
of benef ic 
be made available to the Carr ier for their use in developing 
potential MSP cases with EGHP involvement. 
-9
 &. 
DEPARTMENT OF HEALTH  HUMAN SERVICES 
.f' '110  Memorandum 
June " 1986

Date: 
Gene Hyde	 Refer to: 
Regional Administrator 
From:	 PT AB:JOS

HCF A, Kanas City  2.683

Subject:	 Draft Report on Medicare Secondary Payer (MSP) Working Aged in Missouri 
To:	 Director, Office of Inspetor General

Office of Health Financing Integrity

1100 Main Street

O. Box 26248 
Kanas City, 
Missouri 64196 
Attached are copies of contractors' replies to the findings and recommendations 
in your report. In general, I believe the recommendations to be appropriate
the MSP situation as it existed during the 
period covered in your report, 1983
1984. The recommendations are not fully appropriate to the situation as it exists 
now in 1986. This opinion is baed on the belief that 1) some of the 
recommendations have been implemented in full or in part since 1983 and 2)
budgetary constraints do not presently permit extensive MSP development on
caes prior to 1984. Following are speific comments on your recommendations,
in the order these appear in your report. 
Recommendation 
You recommend "tht HCFA intruct the Medicare contractors indicated in this
report to review all services provided resulting from 
working aged coverage 
" Th  this statement is 
since January 1983. intent of  interpreted to mean
contractors should review Medicare reimbursements for medical services 
covered lnder employer group health plan. You also recommend that applicable
recovery should be made from third  or from providers. 
part payers 
Resoose to Recommendation 1 
Medicae contractors are recovering funds where it is known that coverage also 
exists under employer group health plans. However, this activity is costly and is 
currently funded at a level designed to meet MSP goals established for 1986. In 
addition to funding impediments there is a problem of identification, which is 
dicussed in the response below. The intermediary targeted by your report
intends to pursue recoveries back to 1983 after it has the benefit of automated 
MSP processing and the replies to beneficiary questionnaires have been compared 
to information in prior history. These two actions are now expected to be
operational in late June, 1986. Further information on this point 
may be found in
the letter dated May 14, 1986, from Blue Cross (copy attached). 
RECEIVED 
JUN 1 
OFFICE OF. 
r.OR G  RAC  Page 2

Recommendation 2

You recommend that HCF A instruct the Medicare contractors to establish or 
more effectively identify Medicare 
improve existing Secondary Payer Units to 
secondary payer situations involving working aged. This recommendation springs 
from the finding that the intermediary apparently effectuated MSP recovery in 
one instance but failed to identify three 
additional periods of hospitalization for 
this same beneficiary which were covered at the time under an employer group 
heal th plan.

Response to Recommendation 2 
preparing a mass mailng to  MSP information. 
HCF A is  beneficiaries to elicit 
The replies wil be returned to one point in the country, the results tabulated and 
specific beneficiary data communicated to the appropriate contractor. The 
contractor wil then be required to 
apply this information to beneficiary history 
and to make recoveries where overpayments are discovered. This activity is 
expected to begin within a few weeks. After this program becomes operational 
it should also serve to prevent future Medicare overpayments. 
In the absence of automated programs which allow the application of known !\,1SP 
claims/bils, the contractor must depend on the 
information to subsequent 
or 
provider of services to identify MSP cases on each bil  claim. The 
intermediary described in your report has noted that it receives inconsistent 
information from providers and, therefore, is implementing use of a beneficiary
questionnaire. The results of this questionnaire wil be incorporated into 
automated systems so as to identify. all other MSP situations on the beneficiary 
account. When operational, this system should correct the problem described in 
your report. 
Recommendation 3

You recommend that HCF A ensure that Medicare contractors assist hospitals in 
obtaining essential information to identify working aged individuals. 
Response to Recommendation 3 
made by contractors 
Considerable educational effort has been  since 1983 and 
most of this has been directed to hospitals. However, due to staff turnover in 
the biling and admitting departments, hospitals may easily and quickly return to 
poor performance in identifying MSP situations which, presently, require 
beneficiary co-operation at least one or more times in the identification process.  Page 3

HCF A is preparing to implement data exchange agreements with workmen

compensation agencies. While these are intended to result in obtaining leads to
MSP situations involving workmen s compensation, this project wil concurrently
provide additional leads to working aged cases. In this way, HCFA 
wil have one 
more alternative to beneficiary reporting by which to identify 
working aged 
situations. These agreements are under negotiation now and are expected to be 
operationally productive before October 1, 1986. 
Recommendation 4

HCF A should assure necessary exchange of potential working aged data among
contractors which would prevent overpayments from being made. 
Response to Recommendation 4 
The intermediary reports that a list is being compiled of beneficiaries who have 
EGHP coverage. This wil be sent to the carriers and should serve to prevent 
recurrence of the problem you have noted. 
A is 
Also, HCF  presently assessing a demonstration project in another region,
wherein all MSP information is maintained by one intermediary and all other 
contractors in that state tap into this repository via query processes. If 
successful, HCF A may mandate implementation of similar procedures in other
regions. 
Iv. 
Gene Hyde 
Attachment  .. . 
;' 
..  -.:(.  .;.... . .....  . '.-., '.j ; :':-"---'--,
Crss 
Blue 
Blue Shield 
Ka 
of  City 
3637 Broadway

O. Box 169  General Office 816/561-2300 
Kansas City, Missouri 64141 
May 19, 1986

William E. Fisher, Chief

Policy & Technical Assistance Branch

Division of Program Operations

Health Care Financing Administration

Federal Office Building

601 East 12th Street

Kansas City, Missouri 64106

Dear Mr. Fisher: 
At you request, below please find our comments on the OIG MSP

report:

Finding

Our MSP area is currently funded at a level designed to 
meet the MSP goals established for the Fiscal 1986 year.
Consequently, our efforts are currently being directed at 
savings on claims processed during the current fiscal year. 
Investigation of services rendered since January 1983 would 
be impossible given current funding levels. Additionally,
mcany lcararieri hemalth ins.ur ance contracts have timely filing 
provisions which may prohibit reimbursement of old claims. 
It is possible that the investigation could be completed, 
only to find out that the contract prohibits payment of the
Finding 
Once again, lack of adequate funding has prevented us from

utilizing the experience of the intermediary investigations

for MSP.

If you have any questions on the above information, please

contact me.

Sincerely, 
Crain 
r E 
VRoi  ce President, Claims
 .r , 0 -,:  0w 
I ,  -: 
. :-;;\": . 
; ". . --..  ' (-' ... . ",
Medicae / Geeral 
Amenca 
Par  B / 
O, Box 505

St. Louis, MO 63166 
Phone: (314) 848880 
Toll free: 1-8392-3070 
May 15, 1986

Mr. William E. Fischer, Chief

Policy & Technical Assistance Branch

Division of Program Operations

Federal Office Building, Room 225

601 East 12th Street 
Kansas Ci ty, MO 64106  c: 

:-. v

c."-"? 
RE:  PTAB: JOS 
2. 680 
Dear Mr. Fischer:

Thank you for the opportunity to comment on the OIG draft report of

findings concerning Medicare Secondary Payer - Working Aged in

Missouri. 
The OIG study was based on a period when, admittedly, the MSP program 
was not doing well. This program began to pick up after the 1984
natio 
l MSP workshops, and we feel it has been improving steadily
since. The 1985 workshop at the Regional Office helped the program
to progress. At the 
1986 MSP workshops, the indication was that 
HCFA was more than pleased with the results achieved to date. 
a study were made for the current period, the results would not 
show the MSP-Working Aged program to be working perfectly, but it 
certainly would show the program to be much more effective than it 
was in 1983/1984, the period of this study. 
We reviewed the study. It probably provides a reasonably accurate 
picture of the MSP-Working Aged situation during the 1983-1984 
period. We are not sure of the value of a study that shows how 
this program was functioning two to three years ago - in it' 
infancy, so to speak. 
GENERAL AMERICAN LIFE INSURANCE COMPANY. ST. LOUIS. MISSOURI 63166  May 15, 1986  Page 2

We feel that we, along with all other carriers have made significant

progress in the MSP program during the last two years. 
We continue

to work at improving our procedures and in becoming more effective.

Periodic regional and national workshops have played a very useful

part in this improvement. The "recommendations" in the report have

been implemented already in our opinion.

Sincerely yours,

r;l
ford A  unen 
. nager 
Medicare Benefits II 
CAK:mtd  . "! "".  ..- -\..-'  )-:  . :"'
PlJ-13

Blue Cross.	 Medicare

44 
Federal Medicare  Forest Park 
Intermediary  St. Louis, Missouri 63108-2292 
May 14, 1986

Heal th Cae Finacing Administration Reional  Office
ATI: 
William E. Fischer, Chief PIAB - DPO 
Rom 225 
601 E. 12th Street	 l \

Kasas City, Missouri 
64106 
RE:	 OIG Draft Report of Meicare Secondar Payer provisions 
Working Aged in Missouri 
Dear Mr. Fischer:

This letter is in response to the abve-referenced sumtion concerning
the processing of working aged claims by the Meicare Part A Intermiar 
and the Part B contractors in Missouri.

Ou office 
has thoroughly reviewed the findings and recomrndations of
the Kasas City Regional Office, Office of Analysis and Inspeions
claim 
(OAI) on MSP provisions regarding  involving the working aged 
and TEFRA, 1982. We are aware that a large numr of claims are being
processed by Meicare as 
primary instead of secondary payer. Ou office 
tht 
is also aware of the problem  exists in the identification of claims 
Intermiar 
involving employecr ogrnouipt yhe.a lth plan coverage by both the 
and the provider  CUrently, our MSP Unit is still operating
on a maual basis. A target date of June 1, 1986 has ben set in which 
we will have automated processing capailities which will allow us rrre
time to review claim 
on a prepaid basis for possible employer group health 
cploamn iintvyo lvement. It is also apparent to us tht membrs of the provider
are inconsistent in gathering and relaying MSP informtion to 
incorrec or lack of informtion. 
our office due to  Conseqently, Meicare 
paymnt is being made for som services for which Meicare paymnt should
be secondar. 
Froerq itrhees teh rte atshones ,I notuer romffiiacer  is considering a new approach which would
get verification from the bbenee ficiar for
claim in which primry payer responsibility has not yet  established 
(the source of this verification will be the claims suspended due to a 
y-trailer suspect" error message during the processing function). The
informtion will then be 
relayed to the providers of service who will be
instrcted to anotate their 
records accordingly and bill the appropriate 
purses. 
payer for future billing 
An Equal Opportunity Employer 
Blue Cross Health Services, Inc. of Missouri
Beneficiary Services: 314/658-4351 
Provider Settlement: 314/658-4315  . .
, Mr. William E. Fischer

May 14, 1986

Page 2

The following is our response to the findings and recomndations of the 
OU plans for the areas in 
OAI .  improvemnt as cited by the OAI are 
stated in these responses. 
Response to the recomndations on Finding #1: 
After establishing the beneficiaries with EGHP coverage though
the questionnire,  recomndations for 
(see response to  Findings 2 
and 3) the MSP Unit will research back to 1983 for claims paid by
Meicare for which reimursement from the EG will 
be sought. 
Response to the recorrndations on Findigs #2 and #3: 
The MSP Unit has discovered, though its observation of provider

submitted data, wht appears to be an inconsistency arng all
providers to correctly and routinely collect and report primary 
tht 
payer informtion. It is for this reason  the MSP Unit has 
develope a questionnire that covers all primary payer situations.
Using claim 
suspended as a result of y-trailer informtion on the 
inpatient/outpatient query replies, the MSP Unit will send this

questionnaire directly to the beneficiary if the questionnire has

not ben submi'C'Cea  previ6usly. --The ' response to the questionnire
will be filed into a report on a personal computer. Each subseqent
claim record with a y-trailer will then be suspended and reviewed 
against the tphers onal computer report. If the report shows a prima 
Meicare, the  retured 
payer other  claim will be deleted and 
retured 
along with a printout of the 
beeficiar and will be retured to thqeu epsrtoivoindneari rwei tfhr oinm stthrections
to: 
resubt 
Bill the identified primary payer and then  the 
bills showing this informtion and, 
Keep the printout in their files for future billing reference.

The date on which this informtion is submitted to the provider will 
also be recorded on another report. Subseqebnte  claim billed to Meicare
as prima when the provider has previous I y  inform of Meicare 
status atsh ste condar will be noted in the file and the provider will be
advised 
this informtion was previously submitted to them. Subseqent
and repeted billings of Medicare as primary by the provider which is aware 
tht Meicare is secondary will result in an MSP on-site audit of that
provider. 
Records of this will also be forwarded to the Health Cae 
Fincing Admistration  mae 
Regional Office to  them aware of the 
providers displaying inappropriate billing procedures and lack of

cooperation with outrh otf fice. Any future action to correct the providers

will be decided at  point.
 (. 
Mr. William E. Fischer

May 14, 1986

Page 3

Response to the recommdations on Finding #4: 
The MSP Unit is aware of the nee for better commication 
betwen Intermdiar and carrier. At present tim, a list is
tht 
being comiled of beneficiaries  have EGHP coverage. This 
list will be sent to General Amrican Life Insurance Compy 
and Kansas City Blue Cross/Blue Shield. 
We are optimstic that this approach should reduce the numr of claim
curently processed by Medicare as prima by increasing our capaility 
to detec secondar payer claim on a prepay basis. 
='iu
Sincerely, 
Ro 
;A.
DirecoG.r D,a vCis ontract ldfMrYst 
Governnt Progam Division 
RGD: DS : SIM  , .
Crss,	
Blue  Medicare 
Federal Medicare	 4444 Forest Park 
Intermediary  St. Louis, Missouri 63108-2292	 FO APPROVE 
OM NO. 0938-0214 
Seond 
Meicare 
RE:  Payer Q.estionnire 
De 
Meicae Beneficiar: 
As you may well be awae by no, Meicae no longer maes 
payrt  first (primry)
beficiaforri ealsl.  hPosrpiimtal  or meical services rendered to Mecare
paymt for som serices 
may be the responsibility
of anther 
source, such as: 
AutOlbile, liability, no fault or meical 
insurance 
bErelotywer  group health pltahn  coverage for beeficiaries
thouh their 
the ages of 65  69 or  spouses
uner 
the age of 70 
health plan covrage for beeficiaries
Erloyer group 
entitled to Meicae 
renl  solely on the basis of end stage
disease 
Contion 
Workers  beefits 
Black Lug beefits

Veteran Adstration befits

Q.  be inonn tht 
office has  th  one (or possibly rore) of the primry 
payers listed abve may have  responnsiebisl.i ty of mag first (primary)
pthay mt for you hospSitael nand m eic-.al  Therefore, we are sening
attached Meicae 
Payer Q.stionnire an 
full coration in coleting all  ask for your
retur  qustions tht may apply to you.
Please  attetion in 
tht is  this form to my  th businss reply envelop
enclosed for your conveniene. 
Q. 
th office will then enter your inormtion into ou record an advise
providers of serice of ths inormtion so tht thy ca bill the
appropriate pay first. 
4351 
An Equal Opportunity Employer 
Blue Cross Health Services, Inc, of Missouri

Beneficiary Services: 314/658- Provider Settlement: 314/658-4315
 RE: 
Medicare Secondary Payer Questionnire 
Page 2 
meical 
If you have received hospital or  services recently, you may
have already ben 
asked these questions by the hospital personnel. 
We appreciate any cooperation that you may have given  to  the hospital 
reqest that 
personnel regarding this matter. However, we still  you 
complete this questionnire and return it to our office at your earliest
convenience. 
Should you have any questions regarding this questionnire, please feel 
free to contact our office. 
Sincerely, 
Meicare 
Secondary Payer Unit
Governt 
Programs
Contract Admistration  . .
Crss, 
Blue  Medicare 
Federal Medicare  4444 Forest Park 
FORM APPROVED 
Intermediary  St. Louis, Missouri 63108-2292  OM NO. 0938-0214 
QUETIOOIRE FOR MEDICA SECARY PAYE INFRMTIOO 
S&:IOO I. 
Atm, 
LIABILITY, NO FAULT, MEICA, MARACTICE COVEGE 
Date of accident

City, State

Attorney  corlete 
(Yes/No) If yes,  1-4 
1. Nam

2. 
Address 
3. 
4. City, State, Zip Code 
Telephone
D.  ben filed 
Has claim  under your insurance? (Yes  No) 
If yes, cOlTlete 1-6 
1. Nam of Insurane

2. Addess

3. 
4. City, State, Zip Code 
Telephone 
5. 
Agent 
6.
7. Policy #
E.  Claimb Neu mr
Has claim  filed under other pay s inurance? (Yes/No) 
If yes, comlete 1-9 
1. Nam of Insurance

2. Adress

3. 
4. City, State, Zip Code 
Telephone
5.
Agent
6.  Nur 
Claim 
7. 
Insured Pary
8. Nur
Policy
9. 
Nurr
Claim 
F. 
Have you already recived settlemt? (Yes/No) If yes,
G. Wht was settlemnt arunt?

H. If 
yes to (F.  settlemt to 
exe)s, ,h ave you applied any of your  acc dent
related  either hospital or meical? 
1. If  subt  (Yes/No)
yes,  ' caelled 
copies of receipts, checks, nDney orders,
etc. to verify paymts. 
An Equal Opportunity Employer 
Blue Cross'Health Services, Inc, of Missouri

Beneficiarv Services:  314/658-4351  Prnvirt"r C:"ttl"m"nt' ''IA1,:c;ILII':1C
 . , "" 
Questionnire fer Meicare Secondary Payer Informtion 
Page 2

I. 
If no to (F.), please explain why you did not apply settlement to accident
related expnses, either hospital or 
J.  medical.
abut 
K. Are you still undecided  whether or not to file a claim? (Yes/No)
Did accident occur in place of residence? 
1.  (Yes/No) If yes,
Is residence awed by you? (Yes/No)
If no, did you file a claim for your injuries? 
(Yes/No) If yes,
32..  Nam of ONer ' s Insurance 
Address
4.
5. City, State, Zip Code
6. Agent Name
Policy Numr
7.
Claim Numr 
betwee the 
If you are also  ages of 65 and 69, please be sure to corrlete
Setion I I 
SECION II. 
BE' 
EMIDYER GROUP HETH PLA COVERAGE (BENICIARES  65-69 AN THEIR 
SPOUSES UNER 70) 
A. 
Are you errloyed? (Yes/No) If yes, 
B. Dos your errloyer errloy 20 or rore people? 
(Yes/No) If yes,
C. Wht 
is your present age?

1. Nam of Enloyer
2. 
Address of Emloyer

, 3.
4. City, State, Zip Code 
Group Nam
5. 
Group Numr

6. 
Nurr
Policy 
7. 
Telephone Numr
D. 
E. Are you entitled to Par B Meicae only? (Yes/No)
Is your sIXuse errloyed? 
(Yes/No) If yes,
F. Dos his/her errloyer errloy 20 or rore peple? 
is his/her present age? (Yes/No) If yes,
G. Wht 
12.. Nam of Emloyer

Address of Emloyer

3. 
City, State, Zip Code 
Group Nam 
i" 45. 
Nurr

0tlJ  Group 
6.
Policy Numr
7. 
Telephone Numr
H. Is 
care only? 
he/she entitled to Part B  (Yes  No) 
SECI  III. 
EMYER GROUP HETH PLA COVEG:ER FO R BENFICIARES ENITLD TO MEICA 
SOLEY ON TH BAIS OF END STAGE  DISEAE 
Are you employed?  (Yes/No) If yes,
 . .
Seond 
lEicare 
Payer Informtion
Questionnire f6i" 

Page 3

1. Nam of Erloyer 
2.
Address
3. 
4. City, State, Zip Code 
Group Nam 
5. 
Group Numr 
6. 
17. P.ol icyP NuNmarurr A 
Telephone
B. 
Effecive Date of Meicare Entitlemt
2.  Part B
staed reglar 
First m:mth in which you  course of dialysis
trainng
3. Betw 
the month in whch you staed a reglar course of dialysis
traing (#2. ) and the Par A/B Meicae entitlemt effective
dates (#1.), did 
you receive: 
1.  Traing 
Self Dialysis  (Yes/No)

If yes, state month

Tranplant 
2. Real  (Yes/No)

I f yes, 
state IOnth

entitlemt to 
Is this your first period of  Meicare solely 
renl disease?  on the basis 
of end stage  (Yes/No) If no, list all prior periods of
enti tlemnt. 
From	 Part A  TFroom  Part 

Par A 
Part B

From	 Part A  TFroom  Part 

Par A  Par B

be 
D. 
Have you  errloyed previously but are no longer working?  (Yes/No)
If yes, give date/year of last IOnth worked. 
E. As 	of this writing, have you attained the age of 65?

SEXIOO IV. 
IDRK 
CGENSATIOO COVEGE 
A. 
Date of accident
B. 
City, State
C. 
Attorney? 
(Yes No) If yes, corrlete 1-4 
1. Nam

2.
Address 
3. 
4. City, State, Z p Code
Telephone
D. 
Hav1e . yNou afi led a c a1m 	 or your
 Jur es?  Yes  No) If yes, conlete 1-9
2. of Insurance
Address 
3. 
4. City, State, Z p Code
Telephone Numr
5.
Agent
6. 
Claim Numr
7. 
Numr 
Pol icy  , ,  ; ' 
Questionnaire for Meicare Secondar Payer Informtion 
Page 4 
8.
9. Group Nam 
Group Numr
E. 
Employer Informtion 
1. Nam

23 ..  Address
4. City, State, Zip Code
Group Nam
5. 
Group Numr
6. 
Policy Numr
7. 
Telephone Numr 
F. Nam of Workers Compnsation Board

12 ..  Address 
3. City, State, Zip Code
4. Person Handling Claim 
Telephone Numr
G.  arunt? 
Have you already received settlement  (Yes/No) If yes,
H.  arunt?
I. What is settlemet 
If yes to (G. ), have you applied any of your settlement to accident
related expeses, either hospital or meical? 
(Yes/No) 
If yes, submit copies of receipts, cancelled checks, money orders,

etc. to verify 
paymnts.
J. If 
settlemet to 
no to (G. ), please explain why you did not apply 
meical.
accident related expenses, either hospital or 
K.  aOut 
Are you still undecided  whether or not to file a claim with 
the State Worker Compnsation Board? (Yes/No) 
If you are between the ages of 65 and 69, please corrlete Section II.

l.. 
SECICN V.  :.I  . r  "'.1  '1 _

BUCK LUNG BEFITS THOUGH THE DEPARTM OF LAR 
Lug benefits? 
Are you currently or have you ever been entitled to Black 
(Y1es./ No) If yes,
Entitlement Date 
Ternation 
Date 
comlete Section II. 
If you are between the ages of 65 and 69, please 
SECION VI.  S:, ; 
VES 
AOINISTRTICN BENFITS 
Are you current1y or have you ever been entitled to Veterans Administration 
Benefits? 
1.  (Yes/No) If yes,
Entitlement Date

Termination Date

If you are between the ages of 65 and 69, please complete Section I