In the fall of 2007, the Centers for Medicare & Medicaid Services (CMS) changed the delivery schedule for Medicare Summary Notices (MSNs).  MSNs are the primary means of notifying people of Medicare coverage decisions for recently received health care services, and are an important tool for beneficiary appeals.  MSNs were formerly sent out each month, but are now only being sent out on a quarterly basis.

The original notice that CMS intended to reduce the frequency of MSN deliveries can be found in Transmittal 1347, September 28, 2007 (implementation date, October 29, 2007), Change Request Number 5722.  CMS also added a message to MSNs explaining the change. MSNs, issued on or after October 29, 2007 carry the following general information message (which is also available in Spanish):

If you aren’t due a payment check from Medicare, your Medicare Summary Notices (MSN) will now be mailed to you on a quarterly basis.  You will no longer get a monthly statement in the mail for these types of MSNs.  You will now get a statement every 90 days summarizing all of your Medicare claims.  Your provider may send you a bill that you may need to pay before you get your MSN.  When you get your MSN look to see if you paid more than the MSN says is due.  If you paid more, call your provider about a refund.  If you have any questions, you should call your provider.  (MSN Message:  Revised 38.13)

The key message of this issuance is that beneficiaries may receive bills from providers that need to be paid before they have received an MSN.  Under this circumstance, the beneficiary will not be able to verify in advance of payment whether the amount billed agrees with CMS’s calculation.  This could potentially increase the number of disputes about payments in which the beneficiary will have to seek a refund from a provider.

The MSN, which replaced the Explanation of Medicare Benefits (EOMB) form in 1997, is an important Medicare notice.  The MSN functions as the primary notice for information about decisions on claims for Medicare benefits. Using uniform messages approved by CMS, contractors use the MSN to provide beneficiaries with a record of the services they have received and the status of deductibles and coinsurance amounts.

Prior to October 29, 2007, contractors sent a monthly MSN to each beneficiary for whom a claim was processed during that month, providing information about the disposition of the claims that had been processed on behalf of the beneficiary. Monthly MSNs provided beneficiaries with information about their cost-sharing obligations on a timelier basis, and generally before they received bills from their providers.

The MSN for Part A claims includes the amount of Medicare payment for each service.  Part A contractors send an MSN to beneficiaries for outpatient and inpatient services combined in one notice.  Skilled nursing facilities (SNFs) and durable medical equipment (DME) contractors furnish an MSN to beneficiaries for claims processed for those services.  Part B contractors send MSNs to beneficiaries with information about assigned and unassigned claims.  Information about assigned claims is grouped in a payment information box separate from that for non-assigned claims.

MSNs also contain important information about appeal rights, including a form to use to file an appeal if one disagrees with any of the claims decisions included in the MSN.  The form includes the date by which your appeal must be filed in order for the appeal to be timely (120 days after the date you received the MSN notice containing information about the services with which you disagree).

MSNs contain information that beneficiaries need in order to know if Medicare has paid for their health care and to dispute or appeal payments for services. If MSNs are not delivered timely, unnecessary payments may be made, necessary payments postponed, and appeal deadlines missed.  Monthly MSNs helped to minimize these problems.  Now beneficiaries and their advocates must examine the quarterly MSNs immediately and carefully, and act as quickly as possible, to ensure that important mistakes are not made and that deadlines are not missed.

MINIMUM AMOUNTS IN CONTROVERSY INCREASE FOR 2008

In 2008, beneficiaries wishing to bring appeals before an administrative law judge or the federal court will need to have greater dollar amounts at issue than in 2007, per 72 Federal Register 73348-73349 (December 27, 2007).

The amount in controversy necessary to request an administrative law judge hearing in 2008 is $120.00.

The amount in controversy necessary to request a federal court review in 2008 is $1,180.00.