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Patient Billing / Re: HELP PLEASE! Primary/Secondary and Patient Responsibility
« Last post by PMRNC on October 16, 2017, 08:45:04 PM »
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This is a great topic.  It isn't something that comes up terribly often but when it does it is always a debate.  I know it goes by COB method but I'm still hung up on the fact that the secondary is saying $0 PR.

Well, the secondary paid $35... so yes I'm also hung up on on the $0 responsibility with secondary.   It would help tremendously if we had a full break down of charges and both primary / secondary allowable, payments.



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Patient Billing / Re: HELP PLEASE! Primary/Secondary and Patient Responsibility
« Last post by Michele on October 16, 2017, 06:31:55 PM »
$10 as they owe the copay from secondary :)


But doesn't that violate the contract with Aetna (1199)?

This is a great topic.  It isn't something that comes up terribly often but when it does it is always a debate.  I know it goes by COB method but I'm still hung up on the fact that the secondary is saying $0 PR.
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In my second post I stated that BCBS calculates non-covered charges as patient responsibility therefore they included the extra spinal charge of $40, plus the deductible charge/max per visit of $45 which went towards the deductible and that equals $85.

We are adjusting off the $40 extra spinal charge. Neither insurance considered it as an allowable expense therefore it should not be patient responsibility as per NAIC. Either way, the primary insurance only allows a max of $45 per visit no matter what the total charge. That leaves the following calculations I most recently laid out.


BCBS (primary): Total charges $115 - Allowable  $45  - (went towards deductible)- Patient responsibility $45 - Ins. Paid $0 <Benefits include $500 deduct which isn't met and $45 max per visit>

Aetna (1199-secondary): Allowable $35  - Patient responsibility $0 -Ins. Paid $35 <Benefits include $0 deduct  $0 copay>
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Patient Billing / Re: HELP PLEASE! Primary/Secondary and Patient Responsibility
« Last post by PMRNC on October 16, 2017, 06:03:28 PM »
Somewhere there is a mistake in the original post. The PRIMARY allowed $45 but says patient responsibility is $85 so there is a discrepancy there. Since you say full charges were $110, I'm assuming that the allowable would have been $110 with $45 being applied to deductible leaving patient with $85 balance. (Again, I can't confirm this because there is a big discrepancy with the allowable and the primary payment).   Then.. again going by your original post, secondary only allowed $35 and paid $35. 

I don't want to assume in case you made an error in your original post, but there is def a problem with primary EOB with them allowing $45, applying $45 to deductible and saying patient is responsible for $85. That is where the problem lies.




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Total charges $110: BCBS (primary): Allowable $45 (went towards deductible) - Patient Responsibility $85 - Paid $0
                                        1199-Aetna (secondary): Allowable $35 - Patient Responsibility $0 - Paid $35

Adjustment is $65  (higher allowable of $110-$45)    Primary payment $0. Secondary Payment $35
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The secondary benefits include $0 copay and they also stated that the patient should not have any financial responsibility on the EOB and even when I called and asked them which COB method they used to process the claim.

Patient's plan only allowed a maximum of $45 per chiropractic visit. We billed 3 services: Spinal manipulation-->billed $50, allowed $36, mechanical traction---> billed $25, allowed $9, and also billed extra spinal adjustment $40, allowed $0 which we thought was on the secondary's fee schedule and they would pick it up as an allowable expense. That is why there is a big difference in total charge and allowable.

Michelle, I'm with you! I understand the calculations now but there is still conflicting answers on which is the correct fee schedule to follow.
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Patient Billing / Re: HELP PLEASE! Primary/Secondary and Patient Responsibility
« Last post by PMRNC on October 16, 2017, 03:48:53 PM »
$10 as they owe the copay from secondary :)

but again.. curious .. why was allowable only $45 on $110 charge?
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Patient Billing / Re: HELP PLEASE! Primary/Secondary and Patient Responsibility
« Last post by Michele on October 16, 2017, 03:25:47 PM »
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According to your method, the patient would owe $10 I believe. If I was to honor both contracts or follow the lower fee schedule, the patient would $0.

BINGO.. you got it. :) 


So now I'm confused.....which is correct?
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Patient Billing / Re: HELP PLEASE! Primary/Secondary and Patient Responsibility
« Last post by PMRNC on October 16, 2017, 02:34:53 PM »
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BCBS lists charges which should actually be adjusted off as patient responsibility which is why the PR was greater than the allowable. I am not sure why they have been doing this on our EOR's as we are participating but I am going to disregard that and adjust it off. Here is what it should be:

BCBS (primary): Total charges $115 - Allowable  $45  - (went towards deductible)- Patient responsibility - $45 - Paid $0 <Benefits include $500 deduct which isn't met and $45 max per visit>

Aetna (1199-secondary): Allowable $35  - Patient responsibility $0 - Paid $35 <Benefits include $0 deduct  $0 copay>

According to your method, the patient would owe $10 I believe. If I was to honor both contracts or follow the lower fee schedule, the patient would $0.

BINGO.. you got it. :) 

BUT.. on a side note.. I really want to know why of $115 the primary only allowed $45.
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BCBS lists charges which should actually be adjusted off as patient responsibility which is why the PR was greater than the allowable. I am not sure why they have been doing this on our EOR's as we are participating but I am going to disregard that and adjust it off. Here is what it should be:

BCBS (primary): Total charges $115 - Allowable  $45  - (went towards deductible)- Patient responsibility - $45 - Paid $0 <Benefits include $500 deduct which isn't met and $45 max per visit>

Aetna (1199-secondary): Allowable $35  - Patient responsibility $0 - Paid $35 <Benefits include $0 deduct  $0 copay>

According to your method, the patient would owe $10 I believe. If I was to honor both contracts or follow the lower fee schedule, the patient would $0.
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Patient Billing / Re: HELP PLEASE! Primary/Secondary and Patient Responsibility
« Last post by PMRNC on October 16, 2017, 01:37:39 PM »
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In other words, when calculating patient responsibility, basically use the lower of the 2 fee schedules minus what both insurances paid to find the total. Is that correct?

Yes, I had an idea it would.

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This is what I'm looking at: BCBS (primary): Allowable $45 (went towards deductible) - Patient Responsibility $85 - Paid $0
                                        1199-Aetna (secondary): Allowable $35 - Patient Responsibility $0 - Paid $35.


You did not include the total charges, and in your example the allowable from primary  was $45 but patient responsibility was $85 and your secondary allowable was $35 with them paying $35 .    The patient responsibility from primary carrier of $85 is throwing me as the allowable's from both are so way UNDER that I can't really determine anything w/out knowing the actual charges.
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