Handling patients with multiple insurance policies can mean filing more than one claim and ensuring accuracy across all. However, Medicare has made it easier for medical billers and providers with a crossover claim.
A crossover claim reduces paperwork for the biller and keeps the patient’s insurance coverage updated in the broader healthcare system. Keep reading to know what a Medicare crossover claim is, who is eligible for it, and how it simplifies medical billing.
First the Basics: Medicare, Medicaid, Medigap, & Private Insurance
| Medicare | Medicare is the country’s largest federal health insurance program for people over 65, and younger people with certain health conditions like end-stage renal failure. It’s an earned benefit you get if you or your spouse worked and paid Medicare taxes for at least 10 years. |
| Medicaid | Medicaid is a state and federally funded program to provide healthcare services to low-income people. Since its eligibility depends on one’s financial conditions, its coverage varies across states, and it’s available to people of any age. |
| Medigap | Medigap is a private health insurance that people can buy if they’re enrolled in the original Medicare plan. Its purpose is to fill the gaps left by Medicare, like deductibles and co-pays. |
| Private Insurance | People get private health insurance through their employer or purchase it from the health insurance marketplace. One pays for it as a monthly premium and makes use of it when needed. |
What is a Medicare Crossover Claim?
Medical billing is a multi-stage process; it includes a few crossovers that the biller handles for a provider. When the provider bills Medicare, it pays its part and then, if there’s another insurance linked (like Medigap, Medicare, or a private insurance plan), forwards the remainder to the secondary payer automatically. This process is called a crossover claim, and Medicare does it for the provider so it doesn’t have to bill twice.
Notably, this claim goes through automatically only if the secondary payer is linked with COBA (Coordination of Benefits Agreement). COBA is a program run by the Center for Medicare & Medicaid Services (CMS) to link Medicare with other insurers. This system lets Medicare automatically transfer a claim to other insurers after paying its part, so the provider doesn’t have to send claims separately.
However, if an insurer is not part of COBA (like some private insurances), Medicare doesn’t send a crossover claim. In that case, the provider has to manually bill the next payer in the chain for efficient revenue cycle management.
When a Medicare Crossover Applies
| Situation | What Happens |
| Medicare + Medigap | Medicare pays first and sends the crossover claim to Medigap. |
| Medicare + Medicaid (dual-eligibles) | The same happens; Medicare first, Medicaid second. |
| Medicare + private/commercial insurance linked to COBA | First, Medicare pays its share, and then the crossover claims reach the other payers |
When a Medicare Crossover Doesn’t Apply
| Situation | What Happens |
| If one has a Medicare Advantage (Part C) | There’s no crossover, and the claim goes straight to the Medicare Advantage plan. |
| Medicare + a private plan not in COBA | Provider bills Medicare first, gets an Explanation of Benefits (EOB) statement, and bills the next payer with this statement attached. |
| Patient info mismatch | If all is correct in the Medicare database, it’ll pay. But if patient info is incorrect in the secondary payer’s data, a crossover won’t happen. |
| Claim denied by Medicare | No crossover happens because the secondary cannot pay without a Medicare payment. |
How a Medicare Crossover Claim Works
The provider first submits a clean claim to Medicare, which reviews and adjudicates that claim and pays its share according to Part A or Part B rules. It then issues a remittance advice (ERA/RA) to explain the amount Medicare has approved against a claim (or if it’s denied altogether).
Then, Medicare forwards the claim details to the secondary payer, provided that it’s connected to COBA. That claim transfer is electronic and doesn’t require additional action from the provider.
When Medicare processes a claim, the remittance advice also includes special remark codes to indicate that the claim was sent to a secondary payer and to avoid duplicate claims.
Next, the secondary payer processes the claim as per its rules. Their action may include a payment for cost-sharing or denying services outside their scope. If Medicaid is also present in the chain, it pays last, and once all payers have processed, the remaining balance is billed to the patient.
| Note: A provider cannot bill Qualified Medical Beneficiaries (QMBs). These are low-income patients with both Medicare and Medicaid. A provider cannot bill them for Medicare deductibles, coinsurance, or copays by law. So, Medicaid may cover these amounts left by Medicare, and if it doesn’t, the provider must accept Medicare’s payment as full. Nevertheless, these people cannot be balance-billed. |
What Happens If the Secondary Payer Isn’t Connected To Medicare Crossover?
If the secondary payer isn’t connected to COBA, the provider must bill it directly by attaching the Medicare Explanation of Benefits (EOB) statement, which includes the following details:
- What the provider billed originally
- What Medicare approved
- What Medicare paid and what’s left
The secondary payers use this information to decide if they will cover the leftover amounts, and they cannot process the claim with this EOB.
What the Provider Has to Do to Ensure Auto-Crossover?
The crossover claim process is automatic only if Medicare has accurate information and a clean claim submission is made certain.
Impact of Crossover Claims on a Provider
Delays in crossover claims affect a provider’s revenue cycle. For example, after Medicare clears its share and forwards the claim, the provider expects the remaining balance to show in their account shortly after, but that rarely happens.
Demographic mismatches and payer system lags can increase a practice’s accounts receivable days. Notably, secondary payments that cover deductibles and copayments, etc, may appear small, but they add up, and a provider could be waiting on 1000s in reimbursements that are technically owed but not collected.
Therefore, billing teams must actively monitor remittance advice for all claims to check if they’re forwarded and then track if there are issues at secondary payers’ ends. If a secondary payment doesn’t reach the provider within 30 days (ideally), manual follow-up might be necessary to avoid revenue loss.
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Conclusion
Claims don’t always move effortlessly between Medicare and secondary payers; for billing staff, that means more follow-up and longer revenue cycles. In reality, providers cannot afford these delays because every day a claim sits unresolved is money withheld from a provider.
That’s why BilNow provides end-to-end medical billing services to make sure you see a 25% revenue increase for your practice within 3 months. We take the medical billing complexity off the desk, so no provider has to chase insurance payments.
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FAQs
What happens if the secondary payer denies the crossover claim?
In that case, the provider (or the medical biller that the provider has outsourced its services to) revised the claim to make sure there is no information error. But if the reason for refusal is related to coverage, the patient has to bear the remaining cost. Medicare won’t resend a claim to the other payer because it processes the claim after doing its share, and the rest is the provider’s duty.
Can providers opt out of crossover and directly bill secondary payers?
No, the provider cannot opt out of a crossover claim if the secondary payer is a part of COBA because Medicare automatically transfers the claim to the next payer. But if a crossover fails (because of location or coverage constraints), then a provider can directly bill the secondary payer.
Can crossover work across state Medicaid programs if a patient moves?
A Medicare crossover does not automatically follow a patient from one state to another. Medicaid is run at the state level, and each state has a distinct agreement with it. So if a patient moves, their old state Medicaid will not continue paying. For that, the patient will have to re-enroll in Medicaid in their new state and have their information updated on file with Medicaid and Medicare. Until that, crossover claims will fail, and the provider may need to bill the new state’s Medicaid manually.
