Medical Billing Forum
Billing => Billing => : margemib February 02, 2009, 02:18:09 PM
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Hi Michele,
I was wondering can you send in secondary claims electronicly?
If so how do you get the EOB to go along with that?
margemib ???
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I'm in Pennsylvania and the experience that I have with secondaries is that you have to send them in on paper as you need to submit the primary's EOB along with the bill to the 2ndry ins; otherwise, they would not get the 2ndry EOB if you sent the 2ndry claim electronically. One exception I encountered was with Medicare Region B. If the patient's 2ndry was set up to "cross electronically", then the 2ndry claim is sent electronically by Medicare along with an electronic version of their EOB to the 2ndry ins. Sometimes, though, when you have to refile for whatever reason to the 2ndry payer(never received, denied, etc.), you have to send it paper with a paper EOB. I hope this helps!
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Secondaries can be sent electronically. Your Practice Management system will have a way that you enter the info from the primary eob. Your electronic vendor must set you up for secondary billing, and some of the insurance carriers require testing, but it can be done. If all the info is entered into the PM system you don't have to attach the eob.
Michele
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:DThis is great information to know! (No software I have every worked with has been set up that way.)
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For us it was our electronic vendor. We just needed the right script. It pulls the info from the practice management system and puts it in the right format. We love it. No forwarding eobs & claims on paper! :)
Michele
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Misys has that ability with the utilization of the clearing house Payerpath. Our tech didn't have it set up correctly for 2ndary's at first, but once it was done.........ahhhhhhh love
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Michele,
Also can you tell me what the guidelines are for billing a secondary Ins co for a provider that is a non-par or a par,
after receiving a EOB what charges can you bill for?
margemib
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You have to bill the secondary the exact same charges that you billed to the primary so that they match the eob. You print out a CMS form for the same claim that you billed to the primary and attach the primary eob. It doesn't matter whether the dr is par or not.
Michele
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Can you tell me how you know this? (Trying to convince others is difficult sometimes, so I would like give your source.) Also, will the secondary accept a "non-par" denial from the primary insurance, ex. We are non-par with the primary, but we are par with the 2ndry. Thank you!!
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Michele,
Do you have to adjust the amount according to the EOB on the secondary claim, someone said if the doctor is a par you cannot charge the secondary for the difference between the amount billed and the amount allowed, only a deductable or co-pay, is this true?
margemib ???
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I have dropped the balance (entire) to a secondary claim (2 commercial plans) and they have both paid. I have done adjustments to a primary plan, sent the balance to the secondary and it paid more than I billed. The reason....the primary's allowable were lower than theirs. I have NOT seen any rule that states you have to do the adjustments prior to sending to a secondary policy. I think its just an "unwritten" policy. This is why they get the EOB. They want to see what the primary paid, and they pay the difference in what you billed, what they paid, and what they (secondary allows) Medicare has the same policy when they are secondary. If BCBS allowable on a k0005 is 2000, but Cigna's is 2500 and we billed 3000, my provider is losing on revenue because after BCBS paid the 80% of the allowed, I would have to write off 1000 and only bill Cigna for 400. What is a policy is that you can not bill a patient for more than the allowed if you are a contracted provider.
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I don't really have a source to point you to. It's just something we have learned over the years. We have been told, (and have been billing this way for over 15 years) that you need to bill the same fees to both insurances. You cannot change what you billed (either codes or fees) to the primary when billing the secondary. Once a claim is created in a practice management system it should be used to print both the primary and the secondary. Since you are attaching the eob they can see what the primary allowed and paid. Some secondaries pay only on the balance of the allowed amount, and some use their own fee schedules/allowances to pay.
Think of it this way, you provided services to a patient and enter the services into the computer. Then you create a claim for the primary insurance. When you receive payment and you need to create a claim for the secondary why would you charge anything different than you did for the primary. Your charges should be the same, just let the insurance carriers process them the way they need to.
Michele
Michele
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Will the secondary accept a "non-par" denial from the primary insurance, ex. We are non-par with the primary, but we are par with the 2ndry. Sorry if I missed your answer the first time, but I did not see it. Thank you!!
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Yes they will. If you par with the secondary you just need to attach the eob from the non par company that is prime and they will process.
Michele
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And not doing the adjustments are not "illegal" you are posting what they paid, letting them know whats due (lines 28 29 30 of hcfa 1500) and attaching the EOB. The EOB keeps you honest. You can't say they only paid 10 when they paid 150. Not doing the adjustments first does not mean I am charging the secondary something different, I am billing the secondary whats left over after the primary paid. Its the insurance companys job to look at the claim the eob and determine by their contract what they can pay, and they can pay up to the max of their allowable. What do you do when one payor doesn't allow for a procedure but the secondary does. Medicare doesn't allow for a power seat, but BCBS does. Medicare denies, and it can drop it to patient responsibility, I place Medicare responsibility as 0, but drop the entire balance to the secondary (if it was no secondary, I can then drop to the patient only because medicare stated it was patient responsibility, otherwise i would have to adjust off). What I can not do is drop the balance after the insurance pays to the client if I am a par provider, and they don't have a secondary. In those cases, I adjust off the non-allowed and drop only the copays/ded/non covered items to the patient.
*Try 1 claim and see what happens.*
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I do post the adjustments on my system, but my claim prints out with the original charges and I don't mess with the paid and amount due collumns. I actually had many provider reps tell me leave them alone, they will take the info from the eob. They prefer it that way.
Michele
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Oh, I don't adjust the amounts. I just don't do the primary adjustments. I drop the entire balance from the primary to the secondary.
EX: We bill BCBS 300, they allow 200, and pay 80% ucr. The balance would be 40.00 since they will pay 160 of the claim. I don't adjust 100, then post 160 and leave the 40. I post 160 off the 300 and drop 140 to Cigna. The amount billed with always be the same, the amount paid will be the same, the amount owed on our HCFA will be different. You will only be billing cigna for 40 while I bill them 140.
Cigna looks at the claim, looks at the code, see what their allowables are and pays according. If BCBS paid more than what cigna allowed, they will pay nothing, and the client can't be billed according to your contract. Even if you only drop the 40, you will recieve the same denial code (exceeds our allowable, PR is 0). So why do the adjustment???
I am still researching to see if any laws on billing are against this. I have recovered more for my providers doing it this way. Why would an insurance company tell you to keep the adjustments on???
Also, I only bill like this with commercial insurance. Medicaid has a different guideline and i totally follow that.
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Here is an article that I read on posting secondary insurance. It does describe what is most common (adjust the non allowed)
http://www.chiroweb.com/mpacms/dc/article.php?id=52286
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When I'm posting the primary payment, I put in a contractual adjustment for the amount over their allowance. But that is just in my system. When I send it out I send out the original amount billed along with the eob and let the secondary pay what they will. I find that they do pay more than the primary allows in many cases. I'm not aware of any law against this since I'm charging the same amount to both insurance carriers, and I'm not billing the patient any more than the insurance carrier tells me I can. If I don't record the adjustment from the primary, when the secondary payment comes in I would have to look up the primary if I needed it. This way it's already there. If they pay more, then I just make that adjustment as well.
I guess it's all what works best for you! :) A million ways to get the same outcome.
Michele
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So so true. Neither of us is billing the client for more than the contracted rate.....
Its still good to know how to fish another way *smile*