Medicare Secondary Payer (MSP) Processing—What’s Your Revenue Recovery Potential?

Medicare Secondary Payer (MSP) is generally used when another entity is responsible for paying before Medicare. The MSP regulations were put in place to protect Medicare Trust Funds by preventing Medicare funds from being used to pay for items and services that other health insurers are primarily responsible for paying. Primary payers essentially have the primary responsibility for paying claims. Medicare regulations require that all Medicare Advantage & PACE Organizations (MAOs) that receive payments from CMS for services rendered by beneficiaries must determine whether Medicare is the primary payer. These guidelines are further defined in Chapter 2 and Chapter 5 of the Medicare Secondary Payer (MSP) Manual.

It is critical MAOs remain vigilant in obtaining and maintaining accurate Other Health Insurance Information (OHI) to remain compliant with CMS regulations and maximize revenue. Staying on top of your MSP and Coordination of Benefits (COB) operations is crucial to the integrity of claims payments and MAOs per member per month Part C payment adjustmenMedicare Secondary Payer (MSP) Processing—What’s Your Revenue Recovery Potential?t from CMS. When an MAO is considered a secondary payer, CMS reduces the plan’s Part C Premium payment for that member every month they are flagged as having another insurer paying primary. If that information is incorrect with CMS, and an MAO is paying claims as primary, they could lose tens of thousands of dollars every year that member has an MSP flag set.

Now more than ever, it is to every MAOs advantage to stay on top of their MSP and COB operations for payment integrity. As announced in the recent Advance Notice, MAOs can expect significant changes in 2024 to Medicare Advantage Part C & D Payment Policies. Now is the time to realize all revenue potential by maximizing Medicare premium payments and avoiding claims overpayments. The exact financial impact the payment policy changes will have on each plan is still unknown. As per the Fact Sheet, the agency suggests the net sum of the changes will yield a 1.03% increase in payments while other analysts predict the changes, particularly with the new rules around auditing plans and recouping overpayments, will reduce revenue and force insurers to reduce member benefits and/or raise premium rates.

What’s Your Revenue Recovery Potential?

With so much uncertainty expected in 2024, CODY’s MSP Analytic Tool is a low-to-no-cost way to gain more certainty around your MSP premium adjustments and revenue recovery potential. By leveraging our back-end logic from our CodySoft Recon™ MSP Module, we can perform high-level analytics on a small data set to determine your revenue recovery potential on MSP Adjustments through uncovered/unworked MSP records.

The proof is in the numbers—In a single calendar year, our MSP Analytic Tool identified the following premium revenue recovery amounts:

  • $700K from CMS for an MAO with approximately 32,000 members
  • $500k from CMS for a small MOA with 5,000 members
  • Over $400k from CMS for an MOA with 15,0000 members

We also ran analytics on a small plan with 2,300 members and identified zero dollars in premium revenue to recover. Although we could not offer that plan monetary recovery, we did offer assurance and peace of mind that their current process is operating optimally and not leaving any premium revenue from CMS on the table due to incorrect MSP records.

Our MSP Analytic Tool is an effective, low-cost process that takes less than a month to complete. A select set of CMS data files are required, however IT/BI involvement should not be required.

CodySoft Recon™ – MSP & COB Modules

Identifying your revenue recovery potential is the first step. To realize that potential requires complete analysis and processing through our Software as a Service (SaaS) Modules. CodySoft Recon™ is a highly intuitive system that ingests your plan membership and CMS-generated files to identify workable records. Our system creates transaction IDs for tracking and appropriate dispositioning and produces valuable reporting for downstream processes.

Other Health Insurance (OHI) combines the MSP & COB modules to optimize data management of the CMS Part C & D COB records to produce clean validation records. Our advanced business rules identify duplicates, filter out unusable data, and reduce non-actionable discrepancies/cases.

  • Medicare Secondary Payer (MSP) Module 
    Uses CMS’ Part C MSP file to identify possible records for capitation recovery and validation. Removes duplicates, efficiently groups records, tracks Electronic Correspondence Referral System (ECRS) submissions, and reconciles primacy flags in a claims payment system. Pairs with the COB module to increase efficiency and identify overlaps in CMS files.
  • Coordination of Benefits (COB) Module
    Uses CMS’ Part D COB file and customizable business rules to identify new enrollees and annual records within the CMS regulatory timeframe. Supports updates to downstream claim systems, mitigates risk, increases accuracy, and decreases admin costs.

Leveraged together, our bundled modules and experienced BPO Team provide customers with a full-service MSP/COB process for Medicare Part C & Part D requirements. Our nationwide team of subject matter experts has decades of Medicare experience. CODY’s tenured BPO team accelerates the initial processing and clean-up of newly identified MSP and COB records through our system, enabling customers to see a return on investment within three months of subscribing to our services.

For Plans with an Average Membership of 34,000—Average ROI = 277%

To date, every customer has received a positive Return on Investment (ROI) by subscribing to our MSP & COB services over a 3-year period.

We’re Here to Help—CODY® bridges the gap between health plans serving the Medicare market and the government agencies where they contract. We have led the industry for decades—and have the tools and resources to serve you.

Contact us today to learn more about our MSP Analytic Tool. It’s the first step to verifying your premium revenue recovery potential!

About us: Founded in 2006, CODY® is an Industry leader in Governance, Risk, and Compliance (GRC) Solutions designed exclusively for health plans. We enable over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico to mitigate compliance risk, maximize efficiencies, and improve outcomes. Our Enterprise technology and innovative solutions reduce administrative costs, increase accuracy, ensure regulatory compliance, and provide a better experience for plan members and providers.