Medical Billing Forum
Payments => Patient Billing => : cmpas March 11, 2014, 04:20:19 PM
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Hello ,
I need some help on a issue. patient has 2 insurance and our office participate in both ins and both ins has different allowed amount. If primary allowed amount is more than the sec allowed amount it brings down the patient responsible as per sec ins. Can I just adjust for pri ins and bill the patient for the leftover after sec ins payment which would be more than what sec eob states as patient responsible.
Or should I also adjust the sec ins and bill only what sec ins eob states as pt responsible.
Hopefully someone understood my question and looking forward for an answer. Thank you.
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I would think that you have to adjust per the secondary as you are contracted with both. Any other responses?
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Thank you Merry for your response. I have read in a different blog that we can bill whichever ins has higher allowed amount since we are contracted with both ins. I wasn't sure about it ,that's why I asked my question.
To my general opinion ,since we billing sec for the pt responsible amount from pri ,we should be allowed to bill the patient for rest of the amount after sec pays.
Ex. as per pri pt is responsible for $50. we bill sec ins for that amount
sec says $30 is allowed amount and went to ded.so pt is responsible for only $30.
Do we have to w/o the $20 from pri responsible or we can bill patient for $50.
Appreciate any response. Thank you.
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COB rules say you take the higher of the allowables.
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Ok then I am sending patient bill for $50.Thank you.
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Linda knows best in this case. She worked in the industry
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Ok then I am sending patient bill for $50.Thank you.
If you could post both allowables and paid amounts by both carriers along with CPT and any adjustment remarks it's a good learning tool for everyone on COB. There are some plans that do NOT Coordinate.. (many ERISA plans for example).
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Hi PMRNC,
EX: 99213
UHC(pri) billed allowed ded
$85 $73.93 $73.93
Cigna(sec)billed allowed ded
$85 $53.22 $53.22
HSA paid $53.22.
Should the $20.71 be w/o or billed to pt.
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EX: 99213
UHC(pri) billed allowed ded
$85 $73.93 $73.93
Cigna(sec)billed allowed ded
$85 $53.22 $53.22
HSA paid $53.22.
Should the $20.71 be w/o or billed to pt.
The highest allowable (UHC) $73.93 ($11.07 is your adjustment) The patient owes $20.71
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THANK YOU PMRNC
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What if they have a medicaid hmo as their secondary? And the medicaid hmo won't pay because primary payment is over their allowable. For instance, Primary is aetna, with a $20.00 copay. Aetna pays $48.54 and patient responsibility is the copay. Send to secondary (whose normal allowable is $44.00), they pay nothing.
Can we bill the patient the copay?
THanks
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No, unless the patient has a share of cost. But here is a question. Are you contracted with that particular Medicaid HMO?
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What if they have a medicaid hmo as their secondary? And the medicaid hmo won't pay because primary payment is over their allowable. For instance, Primary is aetna, with a $20.00 copay. Aetna pays $48.54 and patient responsibility is the copay. Send to secondary (whose normal allowable is $44.00), they pay nothing.
Can we bill the patient the copay?
THanks
As Merry mentioned it will be a factor if you are participating with that particular Medicaid/Plan (HMO). Simply being a Medicaid provider (depending on your state) wouldn't matter, it would be that particular HMO plan. In that case NO.. you can't bill the patient for anything as they would have HAD to go to an in-network provider to receive benefits.