Author Topic: Issue with secondary insurance  (Read 3977 times)

PsychBiller

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Issue with secondary insurance
« on: November 06, 2013, 03:29:55 PM »

I have encountered an unusual situation regarding secondary insurance, and I would very much appreciate any input.

We have a patient (child) whose parents are divorced.  As part of the divorce agreement the father is required to provide insurance for the child, which he does (United Healthcare).  The patient's mother also has secondary insurance for the child (Medicaid).

The issue is that the patient's mother has not notified the patient's father that there is a secondary insurance in place. 

Is this legal? should the father not have the right to use the secondary insurance also for his child?

RichardP

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Re: Issue with secondary insurance
« Reply #1 on: November 06, 2013, 03:37:52 PM »
This is my initial thought upon reading your post:  how do you know that the mother has a secondary policy on the child?  The only way that we would know this is if the doctor had a copy of that secondary insurance card.  We have a pediatrician as a client, so we run into situations similar to this.  We put all insurances that are given to the doctor for a patient into the insurance part of our billing software.  When the child sees the doctor, and the doctor gives us the fee slip, we don't know (nor do we care) which parent or friend brought the child in.  We simply bill all insurances we have on file.

Is this not the case in your situation?  Or am I missing something here.

PsychBiller

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Re: Issue with secondary insurance
« Reply #2 on: November 06, 2013, 03:46:41 PM »

I know that she has secondary insurance because I have copies of both cards on file.  I am the practice manager, the mother let slip to me in conversation that the father does not know about the other insurance.

DMK

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Re: Issue with secondary insurance
« Reply #3 on: November 06, 2013, 04:18:20 PM »
The child's care should be billed appropriately to the insurance policies the doctor's office has.  If the father's is primary, and the wife's is secondary, the doctor's office should bill accordingly.  If their is a remaining balance due after both insurances have responded, whoever is the financially responsible party (listed on the intake form) should be billed.

DO NOT get involved in the politics of divorce, this is strictly business, and the office needs to bill it according to the law.

PsychBiller

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Re: Issue with secondary insurance
« Reply #4 on: November 06, 2013, 04:37:58 PM »

I AM NOT getting involved in anything, I do not concern myself with the private lives of patients....the appointments are billed according to the insurance(s) on file.

I simply asked if it was legal for there to be a primary and secondary insurance in place for a child and only one parent have the benefit of using both.


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Re: Issue with secondary insurance
« Reply #4 on: November 06, 2013, 04:37:58 PM »

PMRNC

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Re: Issue with secondary insurance
« Reply #5 on: November 06, 2013, 05:59:01 PM »
Quote
We have a patient (child) whose parents are divorced.  As part of the divorce agreement the father is required to provide insurance for the child, which he does (United Healthcare).  The patient's mother also has secondary insurance for the child (Medicaid).

The issue is that the patient's mother has not notified the patient's father that there is a secondary insurance in place.

Is this legal? should the father not have the right to use the secondary insurance also for his child?

I disagree with the others. You are right in questioning this. First, MEDICAID would be in the child's name not the mothers. 2nd, IF the mother obtained coverage with medicaid w/out notification of the primary.. yes indeed this is an issue.. though it's not YOUR issue.

Here's what I do in that situation. Forget the divorce decree at this point because it's moot.. you have established that the child is covered with UHC..  Contact UHC and let them know you have received information on Medicaid coverage.   LET them tell you what to do. This happens a lot.   IN MANY cases the parent did NOT disclose the father's insurance or liability to Medicaid upon enrollment.  You can also contact Medicaid and just ask them :)   YES.. someone could get into trouble with this, but it won't be you and I commend you for questioning it rather than turning a blind eye which COULD be considered fraud because you suspect a problem.    I SAY cover yourself, make a few calls and let the carriers tell you what to do.

As an FYI, a practice's policies and procedures should contain procedures for situations like this with a divorce.. dr's offices DO have a right (so do insurance companies) in obtaining a copy of the decree to determine primary coverage.   IT should be in the offices policies and procedures.


just as another FYI.. let's assume the patient is indeed qualified for Medicaid due whatever criteria is needed in that state.. THEY would be the last payor, and UHC would be primary.
« Last Edit: November 06, 2013, 06:00:37 PM by PMRNC »
Linda Walker
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shanbull

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Re: Issue with secondary insurance
« Reply #6 on: November 06, 2013, 06:03:30 PM »
Since this insurance is for the child, and both parents are the child's legal guardians, there is no legal reason for you to hide the secondary insurance policy from the father. That is not the mother's private health information exclusively, it is also the child's, and the father has legal access to that private health information because it's his child as well. Since benefit coordination is necessary when there are two insurances, the father needs to know in case he has to contact the primary insurer regarding said coordination (and he probably does, don't be surprised if you start getting denied claims because the insurers are confused). I agree with calling the primary insurance to let them know you found another policy through Medicaid and having them take it from there. That way you aren't really involved and the insurance company will not tell anyone how they found out.
« Last Edit: November 06, 2013, 06:07:21 PM by shanbull »

PMRNC

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Re: Issue with secondary insurance
« Reply #7 on: November 06, 2013, 06:05:31 PM »
Quote
we don't know (nor do we care) which parent or friend brought the child in.  We simply bill all insurances we have on file.

I too bill pediatrics and I can tell you that MANY times it's discovered that the Medicaid was obtained with false information.. When this happens I think we as billers SHOULD care because in 85% of these cases COMMON SENSE prevails. If there is a question the biller is just as responsible.. turning a blind eye doesn't make the situation right. KNOWING COB laws as well as Medicaid laws IS vital as the law does not allow for ignorance. IF We bill Medicaid knowing full well that Medicaid does NOT have record of the primary insurance.. Yes we are responsible. I think he/she was right in questioning this.

Sure we have had patients come back and holler at us because they didn't want Medicaid to know they had other coverage.. but tough nuts.. that's the law. I can't do my job in good conscious if I just "didn't care who was prime".
Linda Walker
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PMRNC

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Re: Issue with secondary insurance
« Reply #8 on: November 06, 2013, 06:07:38 PM »
Quote
Since this insurance is for the child, and both parents are the child's legal guardians, there is no legal reason for you to hide the secondary insurance policy from the father. That is not the mother's private health information exclusively, it is also the child's, and the father has legal access to that private health information because it's his child as well. Since benefit coordination is necessary when there are two insurances, the father needs to know in case he has to contact the primary insurer regarding said coordination (and he probably does, don't be surprised if you start getting denied claims because the insurers are confused).


This is not a question of hiding information from either parent.. that's a separate issue. This is a billing situation.. the office does not have any legal obligation to contact the pateint but they should do due diligence to be sure coverages and who is primary is on the up/up.
Linda Walker
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RichardP

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Re: Issue with secondary insurance
« Reply #9 on: November 07, 2013, 04:55:10 AM »
Linda - I was reponding only to this question that PsychBiller asked:  ... should the father not have the right to use the secondary insurance also for his child?

We don't care who owns the primary and who owns the secondary.  We put both into our database, and both are used when we bill for the service the child receives - regardless of whether the mother or father brings in the child.  So - if this situation occured with one of our clients, the father would get the benefit of the second insurance regardless of whether he knew that it existed.  This seems to be an answer to the actual question asked.  (Note that our statements list all insurances that are active on the account.  So, should there be a balance left for the parent to pay, and if the father is the reponsible party, he will learn of the second insurance when he receives our statement.)

Because the second insurance is medicaid, you have turned the conversation into an answer to a question that PsychBiller did not actually ask.  That is probably a good thing, given that the secondary is medicaid, and I have no problem with what you've said about that.  But I don't think PsychBiller was asking the question you are answering.

PsychBiller said:  The issue is that the patient's mother has not notified the patient's father that there is a secondary insurance in place.

I would think that, if PsychBiller was concerned whether medicaid knew there was a primary insurance on the child in place, PsychBiller would have phrased the concern this way: The issue is that the patient's mother has not notified the patient's father that there is a secondary medicaid insurance in place.

We don't concern ourselves with whether the mother has obtained the medicaid illegally.  Our contract with our clients states that they must give us good information so that we can bill for all monies legally due them for services rendered.  Our client is responsible for verifying ellibility and such as.  Because our contract requires the client to verify the insurance, we assume that the information we get from our clients has been verified and is good.  In spite of all that, we often get involved in figuring out which insurance is actually primary and which is secondary when the carrier billed as primary rejects the claim and tells us that there is other primary insurance on the account.

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Re: Issue with secondary insurance
« Reply #9 on: November 07, 2013, 04:55:10 AM »

PMRNC

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Re: Issue with secondary insurance
« Reply #10 on: November 07, 2013, 10:30:06 AM »
I interpreted her feelings behind the question because the situation does raise a flag. I see what your saying, but I think she was seeing the same question I was.I guess if I wasn't seeing what she was I could easily have said same thing. No big deal. File to UHC and then Medicaid. If Medicaid doesn't know about UHC they will after the primary EOB is attached.  To me thought that could be just as messy later so I had suggested being a bit more proactive.
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Medical Billing Forum

Re: Issue with secondary insurance
« Reply #10 on: November 07, 2013, 10:30:06 AM »