Author Topic: which allowable???  (Read 4519 times)

dekenn

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which allowable???
« on: February 23, 2011, 09:41:58 AM »
This doesn't happen often, but I'm confused about what the patient balance would be:
We participate with both primary and secondary insurances:
Primary insurance allows $30, pays $25. with $5.00 patient copay (which was collected)
Secondary insurance allows $44.67, shows primary payment of $25, and patient liability of $19.67 (44.67 - 25.00)

So, is the patient only responsible for the primary copay of $5, or the additional $14.67 allowed by the secondary???   ??? ???

PMRNC

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Re: which allowable???
« Reply #1 on: February 23, 2011, 10:06:01 AM »
Bare with me as I am not done with my first cup of coffee...You would take the carrier with the highest allowable and their coinsurance would apply, so I am guessing you would need to collect another $14.67   (19.67 - $5 copay paid)  For some reason my brain however is saying I should ask for the original charge.
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rdmoore2003

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Re: which allowable???
« Reply #2 on: February 23, 2011, 12:01:36 PM »
wouldnt you only bill secondary for the copay?
Regina

dekenn

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Re: which allowable???
« Reply #3 on: February 23, 2011, 12:36:21 PM »
the same claim, with the same charges goes to the secondary, it's just marked as "secondary" and
has the primary eob attached

PMRNC

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Re: which allowable???
« Reply #4 on: February 23, 2011, 01:08:39 PM »
Quote
wouldn't you only bill secondary for the copay?

No, you always bill the secondary. There are even secondary plans that are individual plans to which it might even seem the patient is getting more money, that's because they pay an individual premium for the plan. (ie; over insured)

COB rules say you take the higher allowable in determining the adjustment write off/OOP
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rdmoore2003

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Re: which allowable???
« Reply #5 on: February 24, 2011, 10:58:14 AM »
ok, I am a little confused.   I asked this question before and was answered.
If you have a contract with both insurances, primary pays and then pt has a copay or say partial deductible, we of course file to secondary.  but because of the contracts, we are to use the contracted allowed amount.  Was this information not correct.

another ex.     contracted with say medicare primary and bcbs secondary.   medicare allows 50.00, pays 45.00, pt responsible for the 5.00.   send eob and claim to bc they will pay the 5.00 per the primary eob and nothing else. 

Its like you have met your deductible, bc is primary, and pays 100% of allowed amount.  You cannot then turn around and send to secondary of say Aetna.  You have a contracted rate with primary that paid 100%.   If you send to secondary rather in or out of network, isnt this considered double dipping?    Something seems a little fishy, however, I did hit my head this morning.......
Regina

dekenn

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Re: which allowable???
« Reply #6 on: February 24, 2011, 11:29:14 AM »
Not double dipping, but if the insurances have different allowables, depending on their payment rules, they could pay additional money, up to their allowable, but not more than 100% of the BILLED amount.  You would bill the same amount to both insurances, (you don't set up a new claim for the secondary, they get the same claim, same billed amount, just marked secondary, and sent with the primary eob attached.)
This does happen sometimes, with commercial insurances...
my question however is can you bill the patient the higher "patient liability"??
Example:
Billed Amount:   99203  150.00
                      20550  125.00
                      J1094    22.50
                      99213   100.00
Primary Insurance:      
                          Allowed      Paid
99203                   60.00        48.00
20550                   50.00        50.00
J1094                    11.25         9.00
Patient Responsibility:   14.25
99213                   35.00          28.00
Patient Resposibility:   7.00

Secondary Insurance:   
                            Allowed        Co-Ins          Deductible                  Other Carr       Paid
99203                     111.40         11.14              0                                48.00       52.26
20550                       71.40          7.14              0                                50 .00      14.26
J1094                        4.68             .47              0                                 9.00           0
Patient Resposibility (shown on eob):  18.75

99213                     71.96             4.55            26.50                           28.00          12.91
Patient Responsibility (shown on eob):  31.05


SSSSOOOOO....  According to the primary insurance, patient liability is 21.25, but according to secondary insurance, patient liability is 49.80.    Which do I go by?? ??? ??? ???

Michele

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Re: which allowable???
« Reply #7 on: February 25, 2011, 06:55:51 AM »
When you submit a claim to a secondary you are not just submitting what the primary didn't pay, you are submitting the entire claim (original charges just like were submitted to primary) but with payment information from primary.  I think that is where the confusion is coming in.  You are not submitting just the balance or patient responsibility after the primary.  You are submitting the entire claim (with payment info).  It's definitely not double dipping as when all is said and done provider should not have been paid more than the billed amount.  (unless the secondary is a private plan, which is paid for by the patient and they don't go by the primary payment info - which is very rare)

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Michele

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Re: which allowable???
« Reply #8 on: February 25, 2011, 06:59:41 AM »
dekenn,

    I believe Linda is right and that you go by the insurance with the higher liability.  Although I believe most providers do the opposite because they believe they are breaking the contract with the primary carrier.  But the claim was submitted to the secondary with the primary payment info, they processed and calculated (based on the provider's contract) what the patient liability is after taking both payments into consideration.

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PMRNC

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Re: which allowable???
« Reply #9 on: February 25, 2011, 09:23:22 AM »
Quote
I believe Linda is right and that you go by the insurance with the higher liability

Well, it's the higher allowable.   That's the COB rule, to take the higher allowable of the two plans, even if there were a tertiary, again you would take the higher allowable.
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tlewis

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Re: which allowable???
« Reply #10 on: March 15, 2011, 12:53:09 PM »
Under the rules of COB, a secondary carrier may reduce its benefits so that the total benefits paid or provided by all plans during a contract year are not more than the total allowable expenses.  The secondary carrier usually saves money on claims due to the other plan paying first.  These savings are placed in a benefit reserve account or savings bank for the covered person and are used to pay allowable expenses that would have not been paid otherwise.  For example, deductibles, copayments and coinsurance can be reimbursed to the covered person if there are savings available.

Following are simple examples of how claims should be paid in a COB situation.  Plan A is primary and Plan B is secondary.  Both plans pay claims at 80%; the insured is responsible for 20% coinsurance.  For illustrative purposes, Plan A has a $25.00 deductible and Plan B has a $100.00 deductible.  Claims have occurred in one contract year and in consecutive order.

CLAIM #1
Actual Charge = $100.00

Plan A                                                Plan B
$100.00                                              $100.00
   -25.00 Deductible                         -100.00 Deductible
$  75.00                                                    0.00 Payable
         80%                           
$  60.00

Plan A must pay $60.00.  Plan B would make no payment because it had no liability under the terms of the policy if it had been primary.  Also, there was no money available from the benefit reserve account or savings bank.

CLAIM #2
Actual Charge = $5300.00

Plan A                                                Plan B
$5300.00                                           $5300.00
       -0.00 Deductible                            -  0.00 Deductible
$5300.00                                           $5300.00
           80%                                                    80%
$4240.00 Payable                            $4240.00 Payable
             
The deductibles on both plans were calculated in claim #1.  Deductibles will not apply from this claim forward.  Plan A must pay $4240.00.  Plan B must pay the difference between the actual charge and the amount paid by Plan A ($1060.00).   Plan B must now establish a benefit reserve account or savings bank.  This amount is calculated by subtracting the amount it paid from the amount it would have paid if primary ($4240.00 - $1060.00 = $3180.00 benefit reserve account or savings bank).  Now Plan B must go back to Claim #1 and pay the $40.00 balance of the claim out of the benefit reserve account or savings bank ($3180.00 - $40.00 =$3140.00).  The balance of the benefit reserve or savings account is $3140.00.

CLAIM #3
Actual Charge = $110.00

Plan A                                                Plan B
$110.00                                              $110.00
         80%                                                    80%
$  88.00 Payable                              $  88.00 Payable

Plan A pays $88.00.  Plan B pays the difference of the actual charge and the amount paid by Plan A ($22.00).  Now Plan B calculates the amount to be put in the benefit reserve account or savings bank.  Plan B would have paid $88.00 if primary.  It only paid $22.00, so the balance of $66.00 goes into the benefit reserve account or savings bank. (Previous balance $3140.00 + $66.00 = $3206.00).

CLAIM #4
Actual Charge = $1500.00

Plan A                                                Plan B
$1300.00 U&C                                  $1100.00 U&C
           80%                                    __       80%
$1040.00 Payable                            $  880.00 Payable

The insured is liable for the difference between the actual charge and the highest usual and customary (U&C) amount ($200.00).  Plan A pays $1040.00.  Plan B pays the difference between the highest U&C amount and the amount paid by Plan A ($1300.00 - $1040.00 = $260.00).  The benefit reserve account or savings bank is increased by the difference between what Plan B would have paid if primary and the amount actually paid ($880.00 - $260.00 = $620.00).  The benefit reserve account or savings bank increases by $620.00 making the total savings $3826.00.

CLAIM #5
Actual Charge = $1500.00

Plan A                                                Plan B
$1100.00 U& C                                 $1300.00 U&C
           80%                                                     80%
$  880.00 Payable                            $1040.00 Payable

The insured is liable for the difference between the actual charge and the highest U&C amount ($200.00).  Plan A pays $880.00.  Plan B can pay up to what it would have paid if primary.  Therefore, Plan B will pay the difference between the highest U&C amount and what Plan A paid ($1300.00 - $880.00 = $420.00).  The benefit reserve account or savings bank will increase by the difference between what Plan B would have paid if primary and the amount if actually paid ($1040.00 - $420.00 = $620.00).  The prior benefit reserve account or savings bank balance increases by $620.00 to total $4446.00.

CLAIM #6
Actual Charge = $2295.00 for 51 visits
 
This claim involves spinal manipulation.  Plan A provides up to 26 visits per year on an 80% / 20% basis.  The total actual charge of $45 per visit is within U&C limits.

Plan A
$1170.00 U&C for 26 visits
  _______________  80%
$  936.00 Payable

Plan B has no coverage for spinal manipulation.  However, since Plan A has coverage under its policy, the claim is considered an allowable expense.  Plan B must pay the 20% coinsurance ($234.00) amount for the first 26 visits plus 100% of the charges for the additional 25 visits ($1125.00) from the benefit reserve account or savings bank, leaving a final balance in the reserve account of $3087.00. 

NOTE:  The savings generated by COB can only be used within the contract year (usually a calendar year).  At the end of the contract year, the benefit reserve account or savings bank is returned to a zero balance for the new contract year.


tlewis

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Re: which allowable???
« Reply #11 on: March 15, 2011, 01:18:15 PM »
ok this example uses U/C charges. So I can see how this would work if you are not contracted with the insurance companies. However if you are contracted don't you have to accept the contracted rates?  I don't see how the patient is responsible for a higher amount when they have double coverage.

The following items are not required to be considered "allowable expenses":
The extra cost of a private hospital room versus a semi-private room, unless medically necessary according to the insured's physician;
Dental care, vision care, prescription drug or hearing aid programs;
The amount of a benefit reduction under the primary carrier because a covered person does not comply with plan provisions, such as second surgical opinions, pre-certification of admissions or services, or preferred provider arrangements.

tlewis

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Re: which allowable???
« Reply #12 on: March 15, 2011, 01:34:18 PM »
What about secondary plans?
For the purpose of eliminating duplication of benefits, a secondary plan must reduce its
benefits so that the total benefits paid during a claim determination period do not exceed
100% of allowable expenses. Examples of expenses that are not “allowable expenses” are
private room charges and charges that exceed an applicable usual and customary (U&C)
rate or negotiated fee. If one plan uses a U&C reimbursement methodology and the other
plan calculates its benefits per a negotiated fee, the primary plan’s payment arrangement
must be the “allowable expense” for all plans. If a provider has a contract with both
plans, the provider may bill the higher of the two rates, if this is permitted in the contract.

tlewis

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Re: which allowable???
« Reply #13 on: March 15, 2011, 01:59:38 PM »
Key statement "if permitted in the contract". and boy you do not want to be billing a medicare secondary patient the "higher" amount unless you want to get audited.
If in the example used they are both contracted insurance companies I would call look at your contract with the primary before charging the patient the higher co-pay.

tlewis

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Re: which allowable???
« Reply #14 on: March 15, 2011, 05:11:48 PM »
Ok sorry but the math in this one is just really bothering me.. can't let it go. I have looked up the laws for my state ( oregon) and with reference to the payment example I posted I just think that the secondary did not pay this claim in accordance to COB laws. The secondary claim should have paid the claim  with a pt balance of $12.44.
Primary allowed $156.25
Primary paid a total of $135 with a pt balance of $21.25
Secondary allowed a total of $259.44 with a pt balance of $49.80
Secondary must pay as if they are primary but can subtract the amount paid by primary in their calculations. $259.44 -$135.00= $124.44 then they would pay the % they would pay on the $124.44 total. I'm going to assume they pay at 90% because of what they put at the pt's co-pay. so they would pay $112.00 leaving a pt balance of $12.44.
THe secondary shows the co-pay at being a 90% 10% plan. however they did not pay 90% of what they allowed but charged the pt 10% of what they allowed. They cannot use two different calculations to come up with the total. they can't subtract the amount the primary paid to come up with what they owe and not subtract it from the patient. They left the pt responsiblilty as if the primary did not pay but used the the primary payment to subtract from their payment. If we look at J1094 The primary had a a higher allowed amount of $11.25 than the secondary and paid at $9.00 yet the secondary has a lower allowed amount of $4.68 and charged the patient a co-pay of .47 and paid $0.00 I believe that the secondary is going to have to follow the higher allowed amount rule on this one and pay 90% on what the primary allowed so the would need to pay another $1.13 on this claim. which then would bring the pt balance to  $11.11.