Billing Secondary

[dfranklin]

When I have a primary and I am posting the EOB,lets say it is BCBS and I am a PAR provider, I have to write off the adjustment correct?  Now what if I have a secondary? Do I write it off then bill the secondary? Or do I bill the secondary the full unpaid amount?

When I am posting in my current software I do not know if there is a secondary or not.  So I will write off the adjusted amount per the contract with the PAR carrier.  But if I then go to the account I see there is a secondary and it is submitting to them but the amount due is Zero because I wrote it off when I posted the primary EOB because we are PAR with them?

Otherwise if there was not a secondary and I did not do the write off then the balance would become patient responsibility and the system would send out a bill to the patient which is of course against our contract with the carrier.

Any help/suggestions?

Thanks!

[Pay_My_Claims]

first, the problem is your software. You should know if there is a secondary so you can post correctly.

Although we are non par facility, when I worked with one that was par, I NEVER wrote of the adjustments when there was a secondary, unless it was Medicare.
EX: Client has Aetna and BCBS Aetna is primary and we all know their reimbursements are very low. Being par with both, BCBS can and will pay up to the contracted rate minus what the previous provider paid. When you do the adjustments you are NOT billing the client the balance, you are sending the balance to the 2ndary insurance. I learned this since I used to do the adjustments, but when you send in the EOB and the 2ndary pays, you have to go in and fix the allowed amounts because the 2ndary paid more than what was left over. This way I am taking the highest allowed amounts minus the payments to get the clients balance.

[Steve Verno CMBS, CEMCS]

If BCBS is par and primary, it depends on what the contract specifies.  Many contracts have different clauses.  Some allow billing some dont.  Our contract specified if the contract payment is transferred to the patient and the patient doesnt pay.  The contract is in breach.  We are allowed to have the member pay 100% full charges and the debt collection agency's fee. BUT, that was our contract and it took 2 years of negotiations, plus a lawsuit, to get them to agree to that.

[Pay_My_Claims]

but you are not billing the client, you are billing the secondary insurance company. The only thing I have ever seen in any contract is that if you are Par, you accept the rate, and adjust off the balance. This means secondary only pays for copays and deductibles??? No, sometimes the secondary's allowable is higher than the primary, so they will look at the charge, look at what they allow, look at what the primary paid and pay up to their allowed, minus the difference. When they do this, you have to go back and adjust what you posted previously. As I stated, Aetna's allowable are some of the lowest in most carriers. (one reason we will never par with them). If I bill for 100.00 and Aetna allows 20.00 and pays only 15 (5.00 copay) I can bill BCBS only $5.00 ?? BCBS allows 80.00 and pays @80% ucr so they would pay 64.00 minus the 15.00 and pay 49.00. You only have 5.00 as the balance, so you have to do adjustments anyway. When you look at what was paid, and what was allowed, you see the higher allowable was 80.00 and it covered at 80% both carriers paid a total of 64.00 so the client owes 16.00. You can view it as BCBS paid the aetna copay and the client owes his or her 20% and no contract violation has occured.

[PMRNC]

Not sure if there are two questions in this thread or not.. what i am seeing is how to "enter" into your database properly for balance to show on claim to secondary.  This is a data entry thing the way I see it and I'm assuming that the data entry is by someone familiar with COB and the COB and contract rates are known. With that said my claims entry would contain any contractual adjustment and identified on the claim, balance left would show on the claim form and be sent with the EOB from primary to the secondary. I never have to go in and "fix" balances billed to secondary.

[Pay_My_Claims]

there are 2 questions, and i agree, one problem is with the system he uses or as you said a data entry problem.
my post relates to the adjustments. we discussed this before, but if you are par with more than one payor, the contracted rate varies per payor, so there are times where you have to adjust balances if the 2ndary allowable is higher than the primary and they pay more than what is left over by the primary. This is why i don't do adjustments unless there is no secondary to file. The receive the EOB and will pay what is required.

[PMRNC]

This is why i don't do adjustments unless there is no secondary to file. The receive the EOB and will pay what is required.

Not sure I follow. If you have a contractual adjustment why don't you enter it? I'm not understanding maybe.

[Pay_My_Claims]

yes the contract is we can't bill the balance to the client, but doesn't have anything to do with what we bill to the secondary. Its just easier for me
I have had often secondary's that pay  more than the primary. Aetna has low reimbursements. Aetna pays primary on a k0005 900.00 (200 deductible)We bill 2200 if we are in network we accept the allowable and don't balance bill the client. Medicare is 2ndary and allows 1941.20 Medicare will look at what they would have allowed as primary, what the secondary paid, and calculate what is less. They will pay the difference. If I posted the 900 and adjusted off the balance minus the deductible, I bill Medicare only 200.00 This means if medicare pays the difference of 1041.20 I have to change the allowables or else i have a credit balance. What I do is post the 900 (200 is the deductible) and the balance of 1100 drops to medicare. Medicare makes its payment minus the clients 20%. As longs as I don't bill the client MORE than what is left over after Medicare I have not violated any contractural obligations.

[PMRNC]

I'm still confused. Your contractual adjustment is the contractual adjustment. For example if I bill Aetna $100 and the fee schedule is $80, $20 is the contractual obligation and should be entered at the time the payment of the primary is posted. Going back to do contractual adjustments seems counter productive.

[Pay_My_Claims]

I'm still confused. Your contractual adjustment is the contractual adjustment. For example if I bill Aetna $100 and the fee schedule is $80, $20 is the contractual obligation and should be entered at the time the payment of the primary is posted. Going back to do contractual adjustments seems counter productive.

You don't follow...........I don't go back because I don't do the adjustment. What do you do when your secondary pays more than your primary did???
What do you do when you bill 100.00 and INS #! allows 60.00 and pays 40.00 ($20.00 copay).......and the secondary allows 80.00 and pays @ 100% they allow 80-40 from previous payor and they pay you $40.00 When you adjusted off the primary (billed 100, allowed 60 paid 40, you adjusted off 40.00 balance 20.00) now you have to post a payment of 40.00???