Explanation of the Medicare Crossover Claim

Medicare beneficiaries can cover some out-of-pocket expenses through secondary insurance like Medicaid, Medigap, or other retiree plans. In Medicare crossover claims, Medicare transfers a claim to secondary insurance after paying its portion. This situation applies when the patient has more than one insurance. Likewise, Medicare should be the patient’s primary insurance company. A healthcare provider can outsource medical billing services to submit clean claims to payers. Let’s learn more about these crossover claims in this blog.

What is Medicare Crossover Claim?

When a patient (mostly a Medicare beneficiary) is eligible for more than one insurance, the claim is covered under a Medicare crossover claim. Medicare pays its dues and forwards the claim to the secondary insurance company for its payment portion. In this case, Medicare is the primary payer, and it reduces the hassle of submitting duplicate claims.

Working of the Medicare Crossover Claim

It is a systematic process that starts with submitting a claim to Medicare. Afterward, Medicare automatically forwards the claim to the secondary payer so that they can reimburse the provider. If Medicare is a secondary insurance company, it doesn’t fall under the crossover claim category. Let’s look at some important steps included in the process:

Dual Insurance Eligibility Verification: The first step is to verify the patient’s dual insurance eligibility. It is crucial to follow up on the latest information.
Claim Submission: The healthcare staff submits an accurate claim to Medicare to receive the payment for the services rendered.
Medicare Adjudication: After receiving the claim, Medicare processes it. Afterward, it generates the Medicare Remittance Advice.
Automatic Crossover: After paying the claim, Medicare sends the claim and remittance advice to the secondary payer through coordination of benefits.
Secondary Payer Processing: When the secondary payer receives the claim, it reimburses the provider for the services eligible for secondary insurance.

Who are the Eligible Secondary Payers for Claim Submission?

Medicaid

Medicaid and Medicare crossover is the most common. This Medicare crossover claim is for patients who are enrolled in both Medicare (primary) and Medicaid (secondary). Medicare Beneficiaries and retirees are eligible for this crossover.

Medigap

This insurance covers Medicare’s out-of-pocket costs, including deductibles, copays, coinsurance, etc. Although it covers this amount, not all Medigap insurers pay as a secondary payer for the services rendered.

Employer-Sponsored Retiree Insurance

Some companies offer insurance to their employees after retirement. If Medicare pays for a claim after retirement, it sends the claim to the sponsored retiree insurance. Every retiree has different employer-sponsored insurance.

What are the Benefits of the Crossover Claim?

Medicare crossover benefits include:

Reduced Administrative Task: It reduces the administrative tasks due to the automation of claims. Medicare automatically sends the claim to the secondary payer.

Accuracy: The claim automation reduces the risk of claim duplication errors. Furthermore, the provider doesn’t have to submit a claim to the secondary payer.

Enhances Patient Experience: It improves patients’ experiences by reducing out-of-pocket costs.

What Challenges Occur During the Crossover Claim Process?

Payment Delays: Some secondary insurers may delay the reimbursement due to a lag in processing claims.

Eligibility Verification: Non-verified insurance coverage leads to avoidable claim denials.

Denied Claims: Secondary insurers may refuse to reimburse, which requires claim denial management and becomes challenging for providers.

Conclusion

An accurate claim submission is necessary to streamline the revenue cycle. A Medicare crossover claim is when Medicare pays the initial payment and sends the claim to the secondary payer. Likewise, it automates the claim processing, reducing the administrative tasks and increasing efficiency. The eligible secondary payers include Medigap, Medicaid, and Employee-sponsored retiree insurance. In addition, some secondary payers refuse to pay their dues. So, it is essential to verify everything before submitting a claim.

Frequently Asked Questions

Who qualifies for a Medicare crossover claim?

Senior citizens, disabled people under 65, and retirees with primary and secondary insurance coverage are eligible for a crossover claim. In this case, Medicare should be the patient’s primary insurance company.

What is meant by crossover payment?

When Medicare sends the claim to the secondary payer after paying their portion, it is called a crossover payment.

What happens if Medicare is not the primary insurance company?

If Medicare is not the primary insurance company, then the crossover claim doesn’t count in medical billing.