Challenge of getting MSP answers sparks computer, training solutions
December 1, 1999 6 minutes read
Challenge of getting MSP answers sparks computer, training solutions
HCFA gives rave reviews to Portland system; now it’s a model
Imagine being told after an audit by the Baltimore-based Health Care Financing Administration (HCFA) that your organization has a "very pristine process" for filling out the Medicare secondary payer (MSP) questionnaire, and there is probably no need for audits at your system’s other hospitals.
That’s exactly what happened at the Providence Health System in Portland, OR, says Barbara Wegner, CHAM, regional director for access services. In fact, Wegner adds, the auditor asked if the process at Providence could be shared with other health care providers struggling to comply with HCFA’s stringent guidelines for determining if there is another payer who should be primary when a Medicare patient receives medical treatment.
Failure to show that registrars have thoroughly questioned patients regarding whether Medicare should pay the bill can result in fines for each violation and ultimately could cause a facility to lose Medicare eligibility. The False Claims Act, which can come into play any time providers seek improper reimbursement, provides for fines of up to $10,000 per incident.
The positive results at Providence didn’t come easily, says Kellie Friderick, quality assurance and training analyst, who worked closely with access staff after Providence Milwaukee hospital, located in a Portland suburb, was given two months’ notice that its MSP procedures would be examined. The hospital was told to prepare for an on-site audit that would include interviews with staff and a random inspection of 60 Medicare claims, Friderick adds.
"For the past year, we had been trying to bone up on the gathering of information for the MSP form, so we had a lot of documentation and a lot of training materials," she says. "For the two months before the audit, we focused very heavily on preparing that facility." (See related story, p. 135.)
As it happened, the installation of a new set of MSP computer screens coincided with the audit preparation, so training was incorporated into the process, she says. "Our software vendor, [Atlanta-based] McKesson-HBOC had built a new MSP page to comply with the new Medicare regulations that came down in February."
The new computer screens were very different from the two-page computerized MSP form staff had worked with before, Friderick says. "The new system is very much driven by the Medicare regulations and the way they ask the questions. Depending on the answer on one page, there may or may not be another screen flow. Based on patient response, there will be up to five different screen flows [the registrar] may encounter."
The new regulations require that three more MSP questions be asked:
1. Are the services to be paid for by a government program such as a research grant?
2. Have you received a kidney transplant?
3. Have you received maintenance dialysis treatments?
For end-stage renal disease, one of the other conditions mentioned in the MSP questions, "it gets very involved with coordination of benefits and issues surrounding dual entitlement — if there is an employer group plan," Friderick adds.
During the Providence Milwaukee visit, the HCFA auditor met with the on-site access services manager, the compliance coordinator, and Friderick. "She asked basic questions about training and how often we were asking [the MSP questions]," Friderick says. The answer was that we do it on all admissions and outpatient visits. We presented her with our policy, training material, attendance sheet — quite a stack of material — and talked her through it."
The staff left the auditor alone to examine the 60 patient accounts that had been randomly pulled, Friderick says, and then took her to the registration area, "where she asked registrars some pointed questions" about how they handle different patient scenarios. Although no Medicare patients came through the admitting department during that period, Friderick notes, the auditor later was able to observe an emergency department registration of a Medicare patient and follow up with questions.
The exit interview went well, she adds, with the auditor noting that "ours was a very pristine process, as far as the documentation and the audit. She asks us a few questions about the accounts, and we were able to get those answers." One computer-related question had to do with how the data from the patient demographic page pulled forward onto the MSP page, Friderick says, and another with how registrars handle the interview if they suspect the patient may have been in an accident.
"When we interview any patient, if any diagnosis leads us to believe there was an accident, or if there are bumps or bruises, the staff will ask the patient if this is the result of an accident," she explains. "If the patient fell, we ask if it happened at home, in which case Medicare is responsible. If it happened at the grocery store, we would follow that with more questions. It’s a big challenge to gather some of this information."
Storing MSP records can be nightmare’
HCFA requires that health care organizations keep for 10 years documentation showing they have asked patients the MSP questions, notes Karen Dufty, CHAM, director of patient services for Meritcare Health System in Fargo, ND.
"If your software company can’t build in screens so you can store that information, it’s a real nightmare," Dufty says. "You have to make sure you print [the document] and keep it in a paper file, and you have to ask the questions every single time."
Working with its software vendor, Malvern, PA-based SMS, and outside consultants, she adds, Meritcare addressed that part of the MSP nightmare last spring by building into the registration screens all the questions Medicare requires.
"If the registrar just keeps flipping the screens, [the computer] will ask them a question and, depending on how they answer, will immediately take them to another question," Dufty says. "If the patient answers yes’ to the question about being treated for black lung disease, it automatically brings up another set of questions. If no,’ it won’t bring those up."
Dufty advises making the process as easy as possible for registrars. "Have a good screen flow, so they don’t have to think about [the next step]."
Although the software solution is working smoothly, it doesn’t change the fact that patients must be asked the same questions again and again, Dufty says. "Do patients appreciate us asking those questions? No, they really don’t, but we tell them it is a requirement, so they don’t blame us."
The process is particularly onerous for outpatients, many of who come in for regular visits, she points out. "We have a cancer center, and when those patients come in for treatment, we have to work with caregivers as to why we burden patients who are receiving radiation with these questions."
Despite the frequency of visits, outpatients must, according to HCFA regulations, be asked the MSP questions each time. One of her organization’s focuses, Dufty says, has been to make sure "there is not a single area for any service" that fails to do so.
Caregivers are understandably concerned, she notes, when patients complain, for example, "I come in every week, and every time they ask me about this black lung disease."
In addition to educating clinical staff on why the questions must be asked, she says, her facility is experimenting with handling the procedure in a different way. "I think someone like access representatives or registrars, who understand the background, needs to ask the questions," Dufty adds, "because some have to do with whether the spouse is working or whether the spouse has insurance coverage. But there might be a slightly better place or time."
One idea, for example, is to have the patients sit down in the waiting room and let the registrar go to them, rather than have them standing in line or at a desk to answer the questions, she says.
The question of how to meet the MSP requirement when a patient comes in unconscious or incoherent has providers scrambling for answers.
In researching this issue for several institutions in the Northeast, Claudia Hinrichsen, a health care attorney with Nixon, Peabody, LLP’s Long Island (NY) office, informally surveyed access managers across the country. The responses varied from hospital to hospital, but one central theme is significant, she says. Hospitals must make diligent efforts to obtain information in order to complete the MSP questionnaire.
"Attempts should be made to contact spouses or next of kin," she says. "If the patient is unconscious upon admission, make sure there are efforts to go up to the floor when the patient regains consciousness. If the patient comes from a nursing home, call back to the nursing home to get this information. The key is that the institution thoroughly document all efforts to obtain the information."
If access personnel have exercised all reasonable efforts and are still unable to answer all MSP questions, they should document those efforts and explain that they were unable to obtain the additional information, Hinrichsen adds.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content