Author Topic: Primary and secondary ins allowance  (Read 3752 times)

cmpas

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Primary and secondary ins allowance
« on: March 11, 2014, 01:20:19 PM »
Hello ,
I need some help on a issue.  patient has 2 insurance and our office participate in both ins and both ins has different allowed amount. If primary allowed amount is more than the sec allowed amount it brings down the patient responsible  as per sec ins. Can I just adjust for pri ins and bill the patient for the leftover after sec ins payment which would be more than what sec eob states as patient responsible.
Or should I also adjust the sec ins and bill only what sec ins eob states as pt responsible.
Hopefully someone understood my question and looking forward for an answer. Thank you.
« Last Edit: March 11, 2014, 01:22:44 PM by cmpas »

Merry

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Re: Primary and secondary ins allowance
« Reply #1 on: March 11, 2014, 01:24:54 PM »
I would think that you have to adjust per the secondary as you are contracted with both. Any other responses?

cmpas

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Re: Primary and secondary ins allowance
« Reply #2 on: March 11, 2014, 01:38:20 PM »
Thank you Merry for your response. I have read in a different blog that we can bill whichever ins has higher allowed amount since we are contracted with both ins. I wasn't sure about it ,that's why I asked my question.
To my general opinion ,since we billing sec for the pt responsible amount from pri ,we should be allowed to bill the patient for rest of the amount after sec pays.
Ex. as per pri pt is responsible for $50. we bill sec ins for that amount
sec says $30 is allowed amount and went to ded.so pt is responsible for only $30.
Do we have to w/o the $20 from pri responsible or we can bill patient for $50.
Appreciate any response. Thank you.

PMRNC

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Re: Primary and secondary ins allowance
« Reply #3 on: March 11, 2014, 01:54:26 PM »
COB rules say you take the higher of the allowables.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

cmpas

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Re: Primary and secondary ins allowance
« Reply #4 on: March 11, 2014, 01:59:31 PM »
Ok then I am sending patient bill for $50.Thank you.

Merry

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Re: Primary and secondary ins allowance
« Reply #5 on: March 11, 2014, 03:20:51 PM »
Linda knows best in this case. She worked in the industry

PMRNC

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Re: Primary and secondary ins allowance
« Reply #6 on: March 11, 2014, 04:09:31 PM »
Quote
Ok then I am sending patient bill for $50.Thank you.

If you could post both allowables and paid amounts by both carriers along with CPT and any adjustment remarks it's a good learning tool for everyone on COB. There are some plans that do NOT Coordinate.. (many ERISA plans for example).
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

cmpas

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Re: Primary and secondary ins allowance
« Reply #7 on: March 12, 2014, 08:12:52 AM »
Hi PMRNC,
EX: 99213
UHC(pri) billed    allowed  ded
               $85     $73.93    $73.93
Cigna(sec)billed  allowed   ded
                $85     $53.22    $53.22
HSA paid $53.22.
Should the $20.71 be w/o or billed to pt.

PMRNC

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Re: Primary and secondary ins allowance
« Reply #8 on: March 12, 2014, 08:46:37 AM »
Quote
EX: 99213
UHC(pri) billed    allowed  ded
               $85     $73.93    $73.93
Cigna(sec)billed  allowed   ded
                $85     $53.22    $53.22
HSA paid $53.22.
Should the $20.71 be w/o or billed to pt.

The highest allowable (UHC) $73.93 ($11.07 is your adjustment) The patient owes $20.71

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

cmpas

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Re: Primary and secondary ins allowance
« Reply #9 on: March 12, 2014, 09:21:21 AM »
THANK YOU PMRNC

dekenn

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Re: Primary and secondary ins allowance
« Reply #10 on: March 12, 2014, 02:59:01 PM »
What if they have a medicaid hmo as their secondary? And the medicaid hmo won't pay because primary payment is over their allowable. For instance, Primary is aetna, with a $20.00 copay. Aetna pays $48.54 and patient responsibility is the copay. Send to secondary (whose normal allowable is $44.00), they pay nothing.
Can we bill the patient the copay?
THanks

Merry

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Re: Primary and secondary ins allowance
« Reply #11 on: March 12, 2014, 09:55:28 PM »
No, unless the patient has a share of cost. But here is a question. Are you contracted with that particular Medicaid HMO?

PMRNC

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Re: Primary and secondary ins allowance
« Reply #12 on: March 13, 2014, 11:21:36 AM »
Quote
What if they have a medicaid hmo as their secondary? And the medicaid hmo won't pay because primary payment is over their allowable. For instance, Primary is aetna, with a $20.00 copay. Aetna pays $48.54 and patient responsibility is the copay. Send to secondary (whose normal allowable is $44.00), they pay nothing.
Can we bill the patient the copay?
THanks

As Merry mentioned it will be a factor if you are participating with that particular Medicaid/Plan (HMO). Simply being a Medicaid provider (depending on your state) wouldn't matter, it would be that particular HMO plan. In that case NO.. you can't bill the patient for anything as they would have HAD to go to an in-network provider to receive benefits.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com