Is an MSP form required with no patient present?
Debate rages, interpretations differ
The latest topic to have access managers frantically e-mailing their contemporaries across the country is a familiar refrain with a new verse or two. It’s a question of handling the Medicare secondary payer (MSP) form, and it seems the answers are as varied as the states and regions from which they come.
The newest twist regarding the MSP questionnaire, designed to determine whether a source other than Medicare should be the primary payer, is the requirement that providers complete the form even when no patient is present.
"It’s the hottest thing right now," explains Betty McCulley, CHAM, corporate director for admitting and the centralized business office at Baptist Health System in Birmingham, AL. "The Health Care Financing Administration [HCFA] got strict around last October about filling it out on specimens. Even though we don’t have the patient present — just a specimen from the patient that is being tested for pneumonia or some other condition — we have to hunt up that patient and ask the MSP questions."
If the patient is in a nursing home, for example, and perhaps unable to answer the questions, that means convincing someone in the facility to provide the name of a relative, she says. Once that individual is contacted, he or she may or may not know the answers, McCulley adds.
"It is so labor-intensive, and nobody has the staff to do that kind of calling and hunting," she says. "It’s not like people understand what we’re asking, so the integrity of the information is questionable, in my opinion."
Another complication, McCulley says, is that HCFA apparently is requiring this step of hospitals but is not monitoring reference laboratories for compliance. "That hurts us competition-wise, so we are getting shot at from every direction."
"What concerns us," adds Pete Kraus, CHAM, a business analyst with patient accounts services at Atlanta’s Emory University Hospital, "is that a stand-alone lab that’s not part of a hospital doesn’t have to do this. That can take business away from hospital labs because their clientele don’t want their patients bothered [with filling out the form]."
The confusion doesn’t stop there. Baptist Health System has been told by the Medicare intermediary in Alabama that it is required to have the MSP questionnaire completed in such cases, and Emory received similar feedback from its intermediary, say McCulley and Kraus. However, intermediaries in other states have interpreted the requirement differently.
Veritus Medicare Services, the Medicare Part A intermediary for the majority of providers in Pennsylvania, has said that an MSP form is not needed if a hospital does a test on a specimen received from a doctor’s office or on one obtained by hospital personnel at a nursing home or during a home health visit, says Ellen M. Byrne, CHAM, RN, MS, manager of patient access at Community Medical Center in Scranton, PA. (See related story, p. 75.)
A Medicare customer service representative presented an inservice Feb. 16, 2000, for Harris Methodist Fort Worth (TX), reports Linda Powell, director of patient access. It included the following information:
1. End-stage renal disease date will always be required when completing the MSP questionnaire.
2. Always attempt to capture the correct date (for retirement, death of spouse, etc.).
3. Month and year are sufficient for dates.
4. In the case of a hospital receiving a specimen, Medicare does not require an MSP questionnaire (for nonpatients).
5. An MSP questionnaire is required every 30 days on recurring patients.
Louisiana has two Medicare intermediaries, notes Beth Ingram, CHAM, director of patient business services at Touro Infirmary in New Orleans, and each has a different take on the subject. "Mutual of Omaha says it is required but not enforced, and Trispan says it is not required. No one can provide regulations that clarify."
Ingram says her facility hired compliance attorneys whose opinion is that the law does not exclude specimens. "If anyone has the regulation showing them as exclusions, I would really appreciate [seeing it]."
Whether the MSP form should be filled out with no patient present "is a very tough issue for everyone," she adds. "It is a very problematic situation that again is compounded by the vagary of the law. I believe HCFA knows it is ridiculous to expect that you can get this information when you do not even see the patient, but [HCFA] fears the reaction of the Legislature if it comes right out and says that.
"We always have to remember why they instituted this form to begin with," Ingram says, "and that is to protect our tax dollars from being used for services that truly should be paid by a third party. They were trying to protect Medicare dollars from being misspent. If HCFA comes right out and says, OK, we are going to exempt specimens because it is too hard to do,’ they are in essence ignoring the potential of paying for services that should have been covered by someone else."
HCFA rejects new approach
Emory’s attempt to make the MSP questionnaire more user-friendly received a thumbs-down from HCFA auditors, Kraus says. "We tried to combine the series of 23 questions to make them easier to answer while still getting the right answers," he notes. "Although I’m convinced we were making accurate coordination of benefits [COB] assessments, the auditors did not like it one bit. They wanted us to include every question individually."
Because Emory wasn’t able to change the on-line system for asking the MSP questions right away, registrars presented them to patients from printouts for a few months, Kraus says. "The question-and-answer requirements were daunting in manual mode, even with the availability of system prompts on the printed text. It’s hard to recommend the manual approach as a permanent solution. MSP questionnaire compliance is a serious enough issue to warrant a look at stand-alone systems, if the main admission/discharge/transfer [ADT] system can’t cope."
On the other hand, he adds, a competent ADT system can improve the quality of the MSP questionnaire. "Ours prompts the user to answer questions in correct sequence, based on the answers given to previous questions. Certain data, such as retirement dates, are pulled from elsewhere in the system when the questionnaire indicates a patient or spouse is retired. The system determines COB based on which questions are answered and tells the user what it is."
Kraus points out, however, that such help does not excuse the registrar from knowing what is being asked. "Patients don’t always provide straight answers," he says. "Access staff must sense when they’re being bamboozled by ignorant or devious patients. Staff must be especially conscientious in completing all their registration screens, since data in certain fields may work interdependently with the MSP questionnaire."
Another issue, Kraus says, is that systems can be defeated or bypassed if you know their weaknesses. "Until recently, our system had some defects and was failing to automatically generate certain codes we were expecting," he adds. "That got us into trouble during a MSP questionnaire audit. That’s why serious Q&A is essential with MSP questionnaires."
The system was updated in April, Kraus notes, and now takes care of all MSP questionnaire-related codes.
Grass-roots action planned
Members of the Washington, DC-based National Association for Healthcare Access Management (NAHAM) are rallying around the MSP issue, McCulley says, and that organization does have a track record in the area of grass-roots activism.
"A number of years back, [hospital access personnel] were required to have every Medicare patient sign a form saying they were aware of their rights," she says. In every state, the interpretation by Medicare intermediaries was that the hospital had to retain a copy of the forms, McCulley notes. After NAHAM members protested the requirement, which generally was decried as a paperwork and filing nightmare, it eventually was eliminated. "An Important Message From Medicare" still must be distributed to patients, but a signed copy no longer must be kept on file. In fact, she adds, "HCFA claimed it never required that."
McCulley says she and her NAHAM colleagues plan a similar campaign regarding the MSP requirement. Having to fill out the MSP questionnaire for lab specimens is particularly frustrating because when the paperwork for a test is given to the hospital, it includes information on other insurance coverage, she adds. "We verify Medicare coverage on-line here anyway, so it’s almost ludicrous to have to do it."
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