What are Medicare Crossover Claims?

Did you know that according to the United States Census Bureau, nearly 43 million people in the U.S. had multiple insurance plans in 2021? Many of these people owned multiple insurance policies to reduce out-of-pocket costs and fill gaps often left by primary insurance.

When an individual has Medicare insurance and a secondary insurance plan, the reimbursement process works differently. In such cases, Medicare crossover claims ensure beneficiaries receive accurate payments on time. 

Typically, Medicare forwards the claims to the patient’s secondary insurer automatically once it has covered its portion of the payment. Therefore, the process no longer requires two separate bills. The adjudicated data is sent to the secondary payer via the Coordination of Benefits Agreement (COBA) for further processing.

But what steps are involved in the Medicare crossover claims? Do these claims affect billing? More importantly, what are the best practices for seamless billing of crossover claims? Let’s find out in this detailed guide. 

How Do Medicare Crossover Claims Work?

Medicare crossover claims operate via a fully electronic process that flows through the Centers for Medicare & Medicaid Services (CMS) COBA’s system. It is a step-by-step process that includes the following:

Step 1: Claim Submission to Medicare by Provider

The crossover claims process begins with a clean claim submitted to Medicare by the provider using an appropriate form. The CMS-1500 is typically used for professional claims and is submitted by physicians and other clinicians. On the other hand, UB-04 is used for institutional claims submitted by hospitals and facilities. 

A clean claim must include accurate information such as the beneficiary’s:

• Valid secondary insurance information
• Medicare Beneficiary Identifier (MBI)
• CPT/HCPCS procedure codes 
• Applicable diagnosis codes

Step 2: Adjudication and Payment

In the next step, Medicare adjudicates crossover claims (either by Part A or Part B rules of coverage). Afterwards, the allowable amount and deductible requirements are applied. Medicare pays its portion of the approved claim amount based on applicable coverage and payment rules.

After the process, a Remittance Advice (RA) is issued, which contains details regarding adjustments, payment, and claim disposition.

Step 3: Claim Forwarding Through COBA

Sometimes, the beneficiary’s secondary insurance may also participate in the COBA program.

If that happens, CMS uses the COBA process to transfer the adjudicated claim information to participating secondary insurers. This way, the provider no longer needs to submit a separate claim to the supplemental insurer.

Step 4: Crossover Verification Using ERA Remark Codes

The Electronic Remittance Advice (ERA) received from Medicare should always be reviewed and verified. It confirms whether or not the claim successfully crossed over. Typically, a Medicare crossover claim has the following:

• RARC MA18 (claim information forwarded to additional payer).
• RARC N89 (information forwarded to another payer).

These remark codes indicate that Medicare transmitted the claim to the secondary insurer. However, if these codes are absent, it may indicate that the crossover claim did not process successfully.

Step 5: Claim Adjudication by Secondary Payer

As soon as the secondary insurer receives the crossover claim, the claim is processed. The secondary payer processes the claim depending on its own guidelines and benefit rules. 

Thus, the secondary payer may cover some or all of the patient’s financial burden, such as:

• Coinsurance
• Deductibles
• Copayments

Lastly, the payer issues a payment or shares the denial information with the provider.

Note: The secondary payer’s coverage is subject to a specific policy for crossover claims. 

Step 6: Payment Posting and Claim Closing

Once the secondary payer completes adjudication, they send the provider a second ERA. The ERA contains payment and adjustment details. After this, both Medicare and secondary insurance payments are posted to the patient account by the provider. 

Additionally, the provider also reviews contractual adjustments and handles the remaining balances. 

If a remaining patient responsibility exists after all payer adjudication is complete, it may be billed to the patient. Lastly, the account can be finalized/closed after the Medicare crossover claim is processed successfully.

Impact of Crossover Claims on Healthcare Practices

Medicare claims that are crossed over may have serious implications for healthcare practices. Since it is valid for multi-payer insurance, failing to handle these claims efficiently can lead to:

Revenue Disruptions

Delays in claims crossover have a direct impact on the practice’s revenue cycle. Once Medicare adjudicates a claim and forwards it to the secondary payer, a secondary reimbursement is typically expected shortly thereafter. However, crossover processing delays or secondary adjudication can postpone payment and affect cash flow.

Reduced Payment Delays and Lower A/R Days

Medicare crossover claims typically operate with electronic data transfer and submission. This reduces the need for manual resubmission and the chances of human errors. 

Additionally, the payment cycle becomes significantly shorter. It is a smart way to control aging accounts receivable (A/R) and streamline cash flow.

Higher Administrative Burden

Without crossover claims, practices may need to manually submit claims to secondary payers and follow up on outstanding balances. Typically, the billing staff would chase secondary payers for balances, even if Medicare has already adjudicated. 

As a result, more resources would be engaged in this tedious work, adding complexity to the claim work. Medicare streamlines this scenario and reduces the administrative strain on the practice by automatically forwarding the adjudicated claim to the supplemental payer. 

Compliance Violations and Audits

Compliance with Medicare Secondary Payer (MSP) requirements remains important for practices. Proper crossover processing reduces administrative errors, but accurate coordination of benefits information is still necessary.

Since the crossed-over claims are handled electronically, it is easier for professionals to ensure compliance. Additionally, compliance teams have a clear audit trail they can follow if required. 

Best Practices for Billing Medicare Crossover Claims

Billing Medicare crossover claims widely relies on accuracy and compliance. Let’s discuss the best practices to avoid unwanted errors and delays.

Submit Clean Primary Claims 

The primary claim submitted to Medicare should always be compliant and accurate. The claim should not contain any data discrepancies, as even a single error can affect the entire process. Double-check all patient-related information for errors, streamline the steps ahead, and avoid denials.

Maintain Clear Communication

Educate patients regarding the crossover billing process, as it can help set the right financial expectations. Additionally, this provides parties with an opportunity to discuss any confusion regarding the process.

For instance, patients may not always be aware of their copays or other financial responsibilities. Clear communication establishes a professional relationship and helps prevent billing misunderstandings.

Maintain All Records

Providers should maintain a comprehensive record of the crossover process. Ideally, this should include the following:

• Communications from payers and patients
• Claims details 
• Payment trail for reference and verification

Check the RA for Crossover Remark Codes

As mentioned earlier, the RA contains specific remark codes that are essential to billing. Always ensure the RA for a crossover claim includes a suitable remark code. If this code is missing, the claim may not have been processed correctly.

Streamline Medicare Billing with NeuraBill

Creating and submitting Medicare crossover claims is a time-consuming yet necessary part of medical billing. Nonetheless, crossed-over claims provide several undeniable benefits, such as:

• Revenue protection
• Reduction in administrative burden
• Reduced risk of duplicate billing and overbilling

However, if your current in-house billing team struggles to manage such claims, we understand. We recommend opting for third-party medical billing and coding services for clean and compliant claim submission to Medicare and other payers.

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