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Benefit
Integrity |
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Our benefit integrity unit works to prevent, detect, and eliminate Medicare fraud. As a Medicare contractor, TriSpan is responsible for protecting Medicare funds from those who would seek payment for items and services under false or fraudulent circumstances. Fraud-fighting is a cooperative effort among beneficiaries, Medicare contractors, providers, federal agencies and others. TriSpan works closely with the Program Safeguard Contractors to coordinate all activities and communications through a Joint Operating Agreement to ensure the Medicare trust fund is protected, and to ensure that providers and beneficiaries continue to receive a high level of service.
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When a medical provider that has selected us as their intermediary submits a claim for payment to the Medicare program, TriSpan receives the claim and begins processing it. To help keep costs low and for faster service, we use electronic claims submission as much as possible. More than 98 percent of all claims TriSpan receives are submitted electronically, through direct transmission. TriSpan processes over 4 million Medicare claims each year.
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When a claim
is filed, it is reviewed for complete and correct information. If the
information on the claim is correct it is processed for payment. |
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Provider Customer Service Representatives provide top quality service to TriSpan's providers and various government agencies. Our customer service representatives stay prepared to answer questions from our customers by telephone, written inquiry or in person. They must pass a comprehensive test on Medicare regulations and be able to provide detailed answers to a wide array of questions regarding this complex program. TriSpan's provider customer service unit handles over 100,000 inquiries each year.
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On any given day, a TriSpan customer service representative handles numerous questions from providers who want to know specific information about Medicare claims, billing, reimbursement and other issues. | |
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Beneficiary Customer Service Representatives provide top quality service to the beneficiaries (those receiving Medicare benefits), caregivers and authorized representatives. Our customer service representatives stay prepared to answer questions from our customers by telephone, written inquiry, (including email via the Contact Us feature of the website) or in person. They must pass a comprehensive test on Medicare regulations to be able to provide detailed answers to a wide array of questions regarding this complex program. TriSpan's
Beneficiary Customer Service ensures that the Privacy Act guidelines are
followed to protect the rights of all Medicare beneficiaries.
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Beneficiary Customer Service Representatives are prepared to answer questions from beneficiaries and their representatives who may want information ranging from covered services to explanation of the Medicare Summary Notice. | |
| Outreach
Partners assist health care providers in the education of their staff and the
resolution of problems. They are responsible for
organizing and leading provider workshops
and participate in TriSpan's Provider Education and Training Group.
Outreach Partners conduct beneficiary outreaches, participate in Health Fairs, CMS REACH Activities and serve as the liaison for Beneficiary Advisory Committees. |
TriSpan Outreach Partners Representatives schedule and conduct provider workshops related to EMC, DDE, Claims, and MSP. | |
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TriSpan's Medical Review Department works to protect program dollars by ensuring providers follow guidelines published by the Centers for Medicare & Medicaid Services (CMS) . Medical professionals examine claims to see if treatment provided is reasonable and necessary considering the needs of the Medicare patient. To educate providers, Medical Review staff
members conduct provider workshops, teleconferences, and have frequent telephone contact
with providers. Local Medical Review Policies (LMRPs) are developed to
provide guidance on whether an item or service is covered and under what
clinical circumstance it is considered reasonable and necessary.
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TriSpan's team of medical reviewers examine claims and medical records received from providers to ensure that Medicare Trust Fund dollars are being spent in accordance with sound medical practice and within the Medicare program guidelines. |
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TriSpan's MSP staff works on claims where another insurer has primary responsibility in paying for medical products or services. This protects beneficiaries by helping conserve Medicare resources and ensuring that Medicare is the secondary payer to automobile or other liability insurance, group health programs, workers compensation, and some others.
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Like detectives working diligently to protect the public, the MSP staff keeps an eye out for several indicators that show another insurer should be paying the bill that Medicare is being asked to pay. When these "primary payers" are found, TriSpan takes action to recover any money that Medicare paid that should have been paid by other parties. |
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| TriSpan's
Provider Audit Department is primarily responsible for performing audits
of the Medicare cost reports that are submitted annually by hospitals,
skilled nursing facilities and other providers. Other functions include
appeals before the Provider Reimbursement Review Board (PRRB) and the
intermediary, annual wage index reviews, and provider-based status
determinations.
Medicare cost reports are audited to ensure compliance with Medicare laws regulations and instructions. This function is an important component of protecting Medicare program dollars. The objective of the audit is to ensure:
The annual Medicare cost reports are subject to various levels of audits such as desk audit or field audit including full scope audits, limited scope audits and focus reviews. As part of the audit, the auditor will review the financial and statistical data reported by the provider in the cost report. During the desk audit, the auditor will look for items that warrant a closer review. Depending on the Medicare dollars at risk a field audit may be considered necessary. Meeting the objectives of the cost report audit requires the auditor to be familiar with Medicare laws, regulations, instructions as well as cost reporting requirements. |
An auditor will review the financial and statistical data. Some cost reports will be selected for various levels of review. An auditor or team of auditors may spend some 400 hours, or longer, analyzing the cost report and the provider's records. |
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| TriSpan’s
Reimbursement Department is responsible for the many tasks involved in
making appropriate payments to hospitals, skilled nursing facilities and
other providers in the Medicare program. Hospitals and other facilities
annually send TriSpan their Medicare cost reports which reflect details
about patient care, cost of services and other information. These cost
reports are used to adjust the interim payments TriSpan sends to the
provider.
TriSpan makes weekly or other interim payments to Medicare providers for their services. Payments are computed, balanced, authorized, and transferred electronically. These payments are reviewed periodically and adjusted to match the specific services rendered. Usually, additional payments or reimbursement amounts are required following the audit of provider cost reports. Each year, TriSpan provides over $3 billion in payments to Medicare providers. TriSpan’s Reimbursement Department also has responsibility for Provider Statistical and Reimbursement (PS&R) reports, Freedom of Information requests, and various special payment rates and limits.
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Provider Reimbursement makes payments to Medicare providers for services rendered to Medicare beneficiaries. | |
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TriSpan’s Provider Enrollment Unit ensures
that Medicare billing privileges are granted to individuals and
organizations that have proven they are financially sound, responsible,
and accountable business partners. In addition, these individuals and
organizations must meet all applicable requirements and standards for
their profession.
Provider Enrollment comes into play as various health care providers apply to become Medicare providers. Enrolling providers return the applications to TriSpan. TriSpan will either make a recommendation to CMS for approval or denial, or return the application for additional information. After CMS makes a final determination of acceptance or denial, they notify the enrollee of their decision.
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The Provider Enrollment function also
comes into play as various provider types attempt to reassign their
benefits, report certain changes of information,
change ownership, or terminate their Medicare provider number. At TriSpan, we work to protect the assets of the Medicare Trust Fund, as well as the quality of health care services our beneficiaries receive. We work with our provider partners to ensure timely enrollment within the Medicare guidelines. |
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