Medicare Dietitian

Navigating Medicare Insurance Claims: Ensuring Seamless Forwarding to Secondary Insurance & the GA Modifier

Navigating the intricate world of insurance billing, particularly when dealing with secondary insurance claims and Medicare, can be quite challenging. For healthcare providers and administrative staff, understanding the correct processes is essential for seamless claim submissions. This helps maintain efficient operations and minimizes the risk of lost income.

One common situation is when Medicare Part B is the patient’s primary insurance, but you know Medicare will likely deny the claim (we hope to explore this more in a future blog). Despite this, the secondary insurance requires Medicare to process the claim first before they will consider it. This can happen if the secondary insurance policy stipulates that they only cover what Medicare does not. In these cases, it’s crucial to ensure the claim is submitted to Medicare properly so it can be forwarded to the secondary insurance automatically. This process ensures that both insurers are aware of the services provided and can coordinate their payments appropriately, helping to avoid any gaps in coverage or unexpected bills for the patient.

At Kalix, we understand these complexities and strive to simplify the process for you. Our EMR system offers robust insurance billing functionalities designed to streamline your workflow, reduce errors, and ensure that claims are processed smoothly. With Kalix, you can manage your Medicare and secondary insurance billing effortlessly, ensuring that claims are forwarded as needed.

This blog post aims to guide you through what you must do to ensure Medicare automatically forwards claims to secondary insurance. Additionally, we will explore whether the GA modifier is required for this process to occur.

Step 1: Complete the CMS 1500 Form Accurately

The first step is to fill out the insurance bill accurately. Ensure that all fields are completed correctly to avoid delays or denials.

Kalix has data scrubbing functionality, which will detect any errors before the claim is submitted.

Step 2: Indicate Secondary Insurance Coverage

On the manual CMS 1500 form, Box 11D is crucial for indicating that the patient has other health insurance coverage besides Medicare. Here’s how to fill it out:

Box 11D: Mark “YES” to indicate that the client has secondary insurance.

Step 3: Provide Detailed Secondary Insurance Information

Accurate and detailed information about secondary insurance is essential. Make sure to fill out the relevant sections with the following details:

Box 9: Name of the secondary insurance policyholder.
Box 9A: Secondary insurance policy number.
Box 9D: Name of the secondary insurance company.

If you are billing through Kalix, save the clients’ secondary insurance details to their profile. Better yet, request that clients fill out their insurance details for you through online scheduling or their intake forms. They can even upload photos of their ID and the front and back of their insurance cards.

Step 4: Submit the Claim to Medicare

After completing the CMS 1500 form, submit it to Medicare for processing. Ensure that all information is accurate and complete to avoid any delays.

Several methods exist to submit claims to Medicare, including the old-school paper submission (avoid using this method if possible) via your MAC’s Portal or billing software (often via a practice management solution like Kalix or a clearinghouse).

Note: MACs (Medicare Administrative Contractors) are regional organizations that process Medicare claims. You can find your designated MAC based on your location and the type of Medicare services you provide. A list of MACs can be found on the CMS website.

Kalix EMR makes the insurance submission process extremely easy by integrating directly with five leading clearinghouses: Assertus, Availity, Claim MD, Office Ally, and TriZetto. You can submit insurance claims to your chosen clearinghouses with just a click of a button without ever leaving Kalix.

Step 5: Medicare Processes and Forwards the Claim

Once Medicare processes the claim, it should automatically forward the necessary information to the secondary insurance company if Box 11D indicates secondary insurance coverage. This automatic forwarding is part of the coordination of benefits process, ensuring that the secondary insurance can cover any remaining eligible costs not paid by Medicare.

Step 6: Follow Up as Needed

After submitting the claim, it’s essential to follow up:

Check Claim Status: Monitor the status of your claim with Medicare to ensure it is processed correctly.
Secondary Insurance: Verify with the secondary insurance provider that they have received and are processing the forwarded claim.

If using Kalix, you can receive automatic claim status updates and electronic remittance advice against the bill in Kalix without ever leaving the program.

Part 2 – Understanding Modifiers and the GA Modifier

We often get asked if the modifier GA is necessary on an insurance claim for Medicare to send claims to secondary insurance. Let’s explore this topic further in the rest of this blog.

What is a Modifier?

Modifiers are two-character codes added to CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes to provide additional information about the service or procedure performed. They help clarify specific aspects of the service, such as the context, extent, or reason for the service. They can affect the way a claim is processed and reimbursed by insurance companies, including Medicare.

What is the GA Modifier?

The GA modifier, “Waiver of Liability Statement Issued as Required by Payer Policy,” documents that a provider has informed a patient about their potential financial responsibility for services Medicare might not cover. This is particularly relevant when a provider anticipates that Medicare will deny a service as not necessary (we hope to explore this topic more in a future blog). The patient is issued an Advance Beneficiary Notice (ABN), indicating they assume financial responsibility.

However, it’s essential to note that the GA modifier is not necessary for Medicare to forward claims to secondary insurance. The primary mechanism for ensuring claims are forwarded appropriately is the correct completion of the CMS 1500 form. Key to this process is indicating the presence of secondary insurance coverage in Box 11D and accurately filling out other relevant fields that detail the patient’s secondary insurance.

It is a common misconception that the GA modifier must be used to facilitate the forwarding of claims from Medicare Part B to secondary insurance. However, this is not the case. The GA modifier’s role is more about documentation and communicating the patient‘s financial responsibility for non-covered services. While modifiers like GA provide important information about the services rendered and document specific interactions regarding financial responsibility, they are not required for the claim forwarding process.

Conclusion

By accurately completing the CMS 1500 form and indicating secondary insurance coverage, you can ensure that Medicare Part B automatically forwards your claims to secondary insurance. This helps streamline the billing process and reduces the financial burden on patients. Always double-check your forms for accuracy and follow up as needed to ensure smooth processing of your claims. Remember, while modifiers are important for providing detailed information about the services provided, the GA modifier is not specifically required for the claim forwarding process.

Kalix, is designed to simplify your insurance billing process, making it easier for you to manage Medicare and secondary insurance claims efficiently. For more information on how Kalix can help streamline your billing operations, visit our website.

The Physician Quality Reporting System (PQRS) was a quality reporting program by Medicare that applied to all Registered Dietitians (RDs) and other eligible professionals that received payments under Medicare Part B (via CMS 1500 claim forms). To encourage participation Medicare applied a negative payment adjustment (reductions) to all Medicare payments when non-compliance or unsatisfactory reporting occurred.

For the 2016 PQRS reporting period, Kalix was approved by Medicare as a Qualified Registry. To our knowledge, Kalix was the first and only Dietitian specific PQRS Registry.

PQRS is Dead, Long Live MIPS

The Physician Quality Reporting System (PQRS) ended in December 2016 and was replaced by Merit-Based Incentive Payment System (MIPS). MIPS has many similar aspects to PQRS, however, it a new system combining three different quality programs: Meaningful Use, PQRS, and Value-Based Payment Modifier programs. While Registered Dietitians were considered as eligible professionals under the PQRS program, they did not qualify for Meaningful Use or the Value-Based Payment Modifier program.

RDs Do Not Currently Qualify for MIPS

As a brand new program, MIPS has new eligible criteria. At least for 2017 and 2018, Registered Dietitians (RDs) are not considered eligible, click here for further details. There are yet be any announcements about whether the eligible clinician group will be extended for 2019 and beyond.

New Exclusion Criteria

Medicare is seeking to reduce the burden of MIPS program participation by the introduction of new exclusion criteria. Newly enrolled Medicare providers and clinicians with low volume threshold are currently excluded.

Voluntary Participation

CMS has stated that they will allow non-eligible providers i.e., RDs to participate in MIPS during the 2017 and 2018 reporting period on a voluntary basis (without any possible payment adjustments). Unfortunately, there is currently a lack of information about what voluntary participation looks like.

MIPS in a Nutshell

Medicare states that MIPS moves Medicare Part B clinicians to a performance-based payment system providing “clinicians with the flexibility to choose the activities and measures that are most meaningful to their practice.” MIPS performance activities are classified into four categories. Clinicians can select applicable activities from each category.

Quality (replaces PQRS)

Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days. Quality Measures are the same as those included in PQRS 2016. Participation can be via claims, a qualified registry or a certified EHR system.

Cost (Replaces Value-Based Modifier)

No data submission required. Calculated from claims.

Improvement Activities (New category)

Complete up to 4 improvement activities for a minimum of 90 days. There is a list of close to 100 suggested improvement activities. Some examples are listed below:

Engagement of patients through implementation of improvements in a patient portal
Use of telehealth services that expand practice access
Provide peer-led support for self-management
Engagement of community for health status improvement
Evidenced-based techniques to promote self-management into usual care
Use group visits for common chronic conditions (e.g., diabetes)
Practice improvements that engage community resources in supporting patient health goals
Glycemic management services
Implementation of practices/processes for developing regular individual care plans
Implementation of specialist reports back to referring clinician or group to close referral loop
Improved practices that disseminate appropriate self-management materials
Enhanced practices that engage patients pre-visit
Implementation of documentation improvements for practice/process improvements

Advancing Care Information (Replaces Meaningful Use)*

RDs have not been eligible to participate in Meaningful Use/ EHR Incentive Program in the past. Eligible professionals can choose to submit up to 9 measures via a certified EHR technology for a minimum of 90 days. Measures include:

Security Risk Analysis
E-Prescribing
Provide Patient Access
Send Summary of Care
Request/Accept Summary of Care
Clinical Data Registry Reporting
Clinical Information Reconciliation
Electronic Case Reporting
Immunization Registry Reporting
Patient-Generated Health Data
Patient-Specific Education
Public Health Registry Reporting
Request/Accept Summary of Care
Secure Messaging

*If considering voluntary participation, RDs may not need to submit data on these measures.

Predictions & The Future

There are yet be any announcements about whether the eligible clinician group will be extended to include Registered Dietitians in the future. Personally, I am hopeful for future participation. As a profession, we do not want to be excluded from MIPS forever. There could be serious financial implications for Medicare reimbursement rates for RDs in the future.

It is reassuring that voluntary participation by non-eligible clinicians is allowed for the next two years. CMS has also made changes to some of it’s MIPS component programs (i.e., Quality- replacing PQRS and Advancing Care Information – Replacing Meaningful use) to make them more flexibility and hence improving their applicability to non-physician healthcare professionals. I was also pleased to notice a change in CMS’s language, they are no longer referring to healthcare providers as physicians (i.e., Physician Quality Reporting System) but announced officially the use of the term “clinician” instead. This is much more of an inclusive word.

At Kalix, we are dedicated to ensuring our program meets all Medicare’s requirements for the future. We have made the decision to retire our PQRS Registry feature for this year (2017) so that we can concentrate on other new features and functionalities like Telehealth. Participation in the Quality component of MIPS can still be achieved for 2017 via Kalix’s claims and billing functionality. It is our goal that Kalix will have built-in MIPS functionality if (or when) RDs become a MIPS eligible profession.

Tag: Medicare Dietitian

Medicare Claim Forwarding to Secondary Insurance