Author Topic: Referrals when there are two active insurance plans  (Read 3189 times)

Zeecy

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Referrals when there are two active insurance plans
« on: June 17, 2009, 10:01:02 PM »
A patient has two active insurance plans.  He is coming to our office, as his PCP, to get a referral for a specialist.  The specialist only takes insurance A.  Our reimbursement is higher with insurance B.  Can I assume we have to bill the visit for the referral to insurance A anyway?  If we bill to insurance B, will insurance A refuse to pay the specialist?

Was that too confusing?

Maybe it's more simple to ask if the referral has to be billed to the same insurance as the specialist visit.

Thanks in advance!

Michele

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Re: Referrals when there are two active insurance plans
« Reply #1 on: June 18, 2009, 07:23:29 AM »
You can't pick which insurance you want to bill based on reimbursement, you have to go by which insurance is prime and which is secondary. 

Did I miss something?    ???

Michele
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PMRNC

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Re: Referrals when there are two active insurance plans
« Reply #2 on: June 18, 2009, 07:26:20 AM »
Quote
The specialist only takes insurance A.  Our reimbursement is higher with insurance B.

I'd certainly want to know why that is.. ???
But Michele is right, you have to bill both carriers (par or not) in the order of Coordination of Benefits with the patients primary carrier being first and then submitting the primary EOB to the secondary.

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Zeecy

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Re: Referrals when there are two active insurance plans
« Reply #3 on: June 18, 2009, 02:57:06 PM »
At he risk of sounding additionally ignorant, what if the specialist doesn't take the patient's primary insurance? 

If the insurance plans are from the patient & from the patient's spouse, is that how I can know which is primary & which is secondary?

Otherwise, how do I know which is primary? 

Help!

Pay_My_Claims

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Re: Referrals when there are two active insurance plans
« Reply #4 on: June 18, 2009, 03:34:59 PM »
At he risk of sounding additionally ignorant, what if the specialist doesn't take the patient's primary insurance? 

If the insurance plans are from the patient & from the patient's spouse, is that how I can know which is primary & which is secondary?

Otherwise, how do I know which is primary? 

Help!

If the specialist doesn't accept the primary insurance, you still have to bill that first. Lets say you have Cigna and UHC. The specialist is OON with Cigna, but the client has OON benefits. You still have to obtain an OON referral and bill as usual. In order for that provider to bill UHC he has to bill that primary first. He can ask the patient to pay up front and bill the claim non assigned. Some providers don't accept secondary plans except for Medicare/Medicaid.

Determining COB is very important you have to know the rules of insurance to do that adequately.

Zeecy

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Re: Referrals when there are two active insurance plans
« Reply #5 on: June 18, 2009, 04:13:01 PM »
 :-[

Clearly I still have a lot to learn.

For example, what if a patient has 2 insurance plans that don't know about each other?  Is that not kosher?  If, for example, I have a family plan through my job and my husband has a family plan through his job...

I just need to know if there's always a primary vs. secondary, and if so, how to find out which is which?

PMRNC

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Re: Referrals when there are two active insurance plans
« Reply #6 on: June 18, 2009, 04:53:25 PM »
Most times the carrier has determined COB, but you need to understand how COB works. I can give you a general and most common scenario.  Husband and Wife, wife is patient, if wife has her own coverage it's prime, and her husband's is secondary. If it's a child, the birthday rule is generally followed.
Again, this is a quickie scenario.. You must understand COB if you are doing the billing.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Pay_My_Claims

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Re: Referrals when there are two active insurance plans
« Reply #7 on: June 18, 2009, 08:26:03 PM »
:-[

Clearly I still have a lot to learn.

For example, what if a patient has 2 insurance plans that don't know about each other?  Is that not kosher?  If, for example, I have a family plan through my job and my husband has a family plan through his job...

I just need to know if there's always a primary vs. secondary, and if so, how to find out which is which?

That happens a lot, and creates problems. Claims will be hung up because of COB denials. When an insurance finds out (usually during a claims submission) that there is other insurance, they want to get the information to determine COB. The example Linda (PRMC) gave is very basic as she said because other things can factor into that scenario. I will try to see if I can get you some information on COB and post it.

PMRNC

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Re: Referrals when there are two active insurance plans
« Reply #8 on: June 18, 2009, 09:11:53 PM »
We have a really good section on COB in our subscriber area.
but here is an article I have had for a while based on the birthday rule from insure.com

When I worked for the insurance carrier, obviously we had to know COB like the back of our hands, my co-workers called me the COB queen. LOL

Birthday Rule
 
"Birthday Rule" determines whose health plan covers your kids
By insure.com

Sorry, the "birthday rule" does not mean that your HMO has to throw a party for you each year and shower you with gift certificates for free visits to the doctor.

Rather, it is an informal procedure that the health insurance industry has widely adopted to determine coverage when your children are listed as dependents on multiple group health plans.

Under the birthday rule, the health plan of the parent whose birthday comes first in the calendar year is designated as the primary plan.  Note, it doesn't matter which parent is older, since the year of birth is not a factor.  Thus, if your birthday is July 15, 1955 and your ex-husband's is September 17, 1953, your health plan would be considered primary because your birthday comes first in the calendar year.

Children and adults can be covered under more than one health plan.  The practice is common for children of divorced parents, who include their kids on each health plan in order to maximize their benefits and to ensure they are covered when visiting your ex, especially if your ex lives in a different state (remember, most HMO doctor networks are only local).  In addition, if each parent has an employer-sponsored group health plan, their children might be listed as dependents on both policies.

When you're covered under multiple health plans, the plans will have to coordinate you or your children's benefits.  This is one of the reasons a health plan wants to know if you or your spouse has other coverage; it's not just being nosy.

The plans need to coordinate benefits to make sure that neither you nor your doctor is reimbursed for more than 100 percent of the actual cost of your medical claim.  They don't want you pocketing their money.

To prevent those kinds of payment problems, when children are covered under each parent's group health plan, one plan is designated as "primary" and the other "secondary."  The plan that is primary pays the cost of the claims first.  The secondary plan pays any remaining costs not covered by the primary plan but only if the medical care is actually a covered benefit under the secondary plan; it won't reimburse you for services it doesn't cover.
Exceptions to the rule

Now for some exceptions.  And hang on to your seats, because this gets a bit complicated.

    * Same birthdays.  If both parents happen to have the same birthday, the plan that has covered the parent longer pays first.

       
    * Divorce or separation.  When two or more plans cover your children as dependents when you are divorced or separated, the plan of the parent who has custody pays first.  The plan of the new spouse of the parent with custody pays second.  And finally, the plan of the parent who doesn't have custody pays last.

      There's also an exception to that custom, though.  If a court has issued a divorce decree stipulating that one of the parents is more responsible for the health care expenses of the children than the other parent, regardless of custody, the responsible parent's plan pays first but only if that insurer knows about this arrangement.

       
    * Active employees.  If you are currently employed and have health insurance through your employer and your spouse has coverage through a former employer (such as COBRA) and your children are listed as dependents on both plans, your plan would be considered primary.

       
    * None of the above.  When none of these rules determines the issue, the plan of the parent who has been covered longer is designated as primary.

       
    * Different plan types.  If you and your ex-spouse have different types of health plans, the rules are also different.  If you have a group health plan and your ex has an individual plan, the group plan pays first, regardless of the birthday rule.

Word of warning

Remember, these are not insurance laws; rather they are common practice, and not all plans follow these customs.  Thus, you should read your policy or membership agreement to see what procedure your health insurer has in place.  If you're still uncertain, contact your plan's customer service department.  And make sure you know the payment procedure before you or your children visit the doctor, lest you be stuck with some unexpected medical bills.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Zeecy

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Re: Referrals when there are two active insurance plans
« Reply #9 on: June 18, 2009, 10:29:18 PM »
Thank you all so much!  You have been most helpful.  I hope one day to be able to reciprocate, or at least to pass my to-be-aquired knowlege on.

Pay_My_Claims

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Re: Referrals when there are two active insurance plans
« Reply #10 on: June 19, 2009, 08:08:04 AM »
You will, its not that difficult to learn. I have been dealing with it for years since I worked in insurance verification.

Pay_My_Claims

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Re: Referrals when there are two active insurance plans
« Reply #11 on: June 19, 2009, 08:11:21 AM »
We have a really good section on COB in our subscriber area.
but here is an article I have had for a while based on the birthday rule from insure.com

When I worked for the insurance carrier, obviously we had to know COB like the back of our hands, my co-workers called me the COB queen. LOL


Present company excluded, my feelings for insurance company workers doing COB isn't great. Everyone that I have dealt with will find out about another insurance and have it primary just to hold up the claims. Do you know that one time I verified Medicare using Passports and the CWF showed medicaid!!! I kept that for years to show how people can screw up. You have to know your ish!