Poll

Medicare coinsurance amounts - is the Patient liable regardless of the secondary's processing? Even if you are contracted with the secondary ie:Blue Shield?

true
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false
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Total Members Voted: 2

Author Topic: Medicare Co-insurance Amounts  (Read 2588 times)

alaughery01

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Medicare Co-insurance Amounts
« on: April 21, 2010, 07:12:07 AM »
I am having a problem with Medicare coinsurance amounts. If medicare says the coinsurnace is 6.00 and blue shield says medicare paid in full is the patient still liable for the $6.00

Anand

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Re: Medicare Co-insurance Amounts
« Reply #1 on: April 21, 2010, 08:00:33 AM »
As long as Mcr paid and if there is bal left over which is pt resp, MCR would cross over directly to sec payor if this is the case it would directly reach the pt's home plan and they would process the claim and pay for it.

I am not quiet getting your stuff bec as long as sec ins process the claim with primary EOB/EOMb they can certainly look what is the payment and pt's resp.. some instances sec would apply the bal towards pt's co-ins/ded [out of pocket expenses] or clm can be denied as pri pd max..

Did you call the ins? if yes, pls ascertain to ask the above questions and let us know on the findings..

Thanks,
Anand

Pay_My_Claims

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Re: Medicare Co-insurance Amounts
« Reply #2 on: April 21, 2010, 09:08:54 AM »
it depends on what type of plan it is. OK you bill 25.00 to medicare. and they allow 15.00 and pay at 80% and pay 12.00. the claim goes to BCBS which isn't a supplement or medigap, but pays on a fee schedule. They are a secondary plan. They allow 10.62 for the code, therefore MEDICARE paid the plan in full. if you are in network, you can't bill the patient.

DMK

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Re: Medicare Co-insurance Amounts
« Reply #3 on: April 21, 2010, 10:12:33 AM »
Charlene hit it right on.  1st - what is the allowed amount from Medicare?  2nd - what is the allowed amount for the secondary?  If Medicare paid more than the secondary allowed, it's been paid in full, the secondary and the patient don't owe.  HOWEVER, make sure the patient's secondary doesn't have a deductible or co-pay to be met by the patient, if that's the case the patient would have to pay the co-pay to the secondary's allowed amount.  Really check the notes on the secondary EOB.  Based on what you wrote, Medicare paid the same or more than the secondary's allowed amount. 

alaughery01

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Re: Medicare Co-insurance Amounts
« Reply #4 on: April 21, 2010, 12:14:38 PM »
I am in agreement. The problem I am having is Medicare is primary they pay all but the $6.75 co-ins amount. We then bill blue shield who's allowables are less than medicare and they say that MC pif. My administrator says that blue shield must either pay the $6.75 or make it due by the Patient but it must be paid by one or the other not written off as a contractual adj. my problem is we are contracted with the Blues so we must accept their fee schedule and take the adjustment. If they are not happy then they need to neg a higher fee schedule.

DMK

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Re: Medicare Co-insurance Amounts
« Reply #5 on: April 21, 2010, 01:20:29 PM »
It wouldn't hurt to call the secondary and verify that.  We are Medicare and Blue Cross contracted.  Most of our patients who have Blue Cross as their secondary get their co-pay and deductible paid at the Medicare rate, some Blue Cross plans, however, only pay up to the Blue Cross rate which is less than Medicare.  So they pay the deductible to the B/C rate, and pay no co-pays as M/C paid more than the B/C rate.

The phone call will be ammo for the discussion with the Provider.  Gotta have your back up info!

Pay_My_Claims

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Re: Medicare Co-insurance Amounts
« Reply #6 on: April 21, 2010, 01:24:26 PM »
It wouldn't hurt to call the secondary and verify that.  We are Medicare and Blue Cross contracted.  Most of our patients who have Blue Cross as their secondary get their co-pay and deductible paid at the Medicare rate, some Blue Cross plans, however, only pay up to the Blue Cross rate which is less than Medicare.  So they pay the deductible to the B/C rate, and pay no co-pays as M/C paid more than the B/C rate.

The phone call will be ammo for the discussion with the Provider.  Gotta have your back up info!

UHC secondary plans are the same. they don't flw medicare guidelines. they don't pay the ded/coins. they see what medicare pays, and what they allow. virtually paying nothing for the visits.