Medical Billing Forum
Billing => Billing => : dfranklin August 19, 2010, 04:35:44 PM
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when a patient presents you with 2 different insurance cards ie Medicare and Anthem BCBS how do you know which is primary and which is secondary? I have seen it where typically Medicare is primary, but i have also seen it where Medicare has denied and said there is another payor that the claims must be sent to.
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When you verify the patient's benefits and eligibility information, you can try to talk a representative and ask if Anthem BCBS is primary or not. Also verifying with Medicare, the CWF will indicate if patient has another insurance coverage that is primary over medicare. If both suggestions dont work. Ask the patient. Also find out if ANTHEM BCBS is an HMO PLAN, if it is then medicare is secondary and Anthem is primary.
Hope this helps and not confuse you more.
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Not confusing...thanks for the reply. I was hoping to avoid having to call everytime. I use an integrated onilne eligibility within our PM software but we have to know the positions first before running it. But I guess we will have to call on these ones first. Thanks!
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Another way to sometimes tell without calling is:
Who is the anthem insurance thru? The patient or the spouse? Can you tell if that person is working or retired? (Sometimes it is indicated on the intake sheet or demographics form) If the Anthem is thru someone who is currently working it is most likely prime (although not always, if there is less than a certain number of employees, Medicare may still be prime) but if the person is retired, Medicare is prime.
You can't always be sure this way, but it tends to push you in the right direction. Of course, calling is the only way to be 100% sure, but as a billing service we can't possible call on every patient. We rely on the provider's office to indicate prime or secondary. They are not always right, but in most cases they are.
Michele
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You can't always depend on the insurance company, because they don't always know about the other payor. You should be doing a COB on the client especially when Medicare is involved. If you KNOW that the COB is incorrect and you bill simply because Medicare says its primary and the insurance says they are secondary, but by the COB rules the insurance is primary, you MUST bill correctly.
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I would say about 80% of the time you only need to call the carrier as they have already established primary..especially if it's Medicare..so the first thing I do if it's in question is to contact the carrier. If the carrier does not have primary on file then I go to the COB rules :)
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but as a billing service we can't possible call on every patient. We rely on the provider's office to indicate prime or secondary. They are not always right, but in most cases they are.
Michele
So you don't provide verification as a service??? And when it comes to COB"s and Medicare I ALWAYS double check. I'm held responsible for filing correctly. I DTA!! I guess i'm anal, but I worked at a major hospital and was the Medicare COB officer there. We didnt play with that. We just had a recoupment from Cigna for 28,000 because they paid in full, and now Medicare is primary. since cigna only pays the 20% we took a loss on the claim.
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No we don't. We have never had any major problems in 16 years. Lucky I guess. We really don't get many patients that it's not very clear who is prime. If we can't tell, we will call to verify. Otherwise, we bill it as it is indicated. I'm a perfectionist, but not anal. I'll say a prayer for ya though! JK ;)
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LOL, i know the issues of COB and you have been lucky I guess. One of the biggest problems that I have seen in medical offices is verification of insurance. The office I worked at that was the first change I made. They only looked and loaded info from the cards. If a client had Medicare & a private insurance they ALWAYS put Medicare primary. Now with the increase in Medicare replacement plans, I double check medicare coverage. The Optometrist that I bill for has a 9% denial rate due just to COB issues with sending claims to Medicare when the client actually has a replacement plan. Its one of my marketing tools!!
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Ahh, yes the replacement plans have caused some issues. We ask our offices to ask all Medicare patients if they've 'signed up for anything new lately' and also 'have you been given any other medical cards?'. This helps. They provide us with all cards, then we can determine from there.
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I definitely do the verifications and eligibility checks..they are the most crucial part of the reimbursement process, most problems can be avoided by doing these!
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I definitely do the verifications and eligibility checks..they are the most crucial part of the reimbursement process, most problems can be avoided by doing these!
I so agree with you on this Linda. Again one of my marketing tactics. I just emailed a provider who switched me from Full Practice to AR-Recovery services. I ran the report from when I did the FP and my denial rate for eligibility was 0%, they had 458 denials and 20% were from eligibilities. The other was coding issues and policy # rejections (bcbs subscriber identifier, and medcost group numbers). I am pushing towards getting that client back up to full practice with me again. The issues was within his office and now he realizes it...