Author Topic: secondary reimbursement rates?  (Read 75 times)

acoleman

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secondary reimbursement rates?
« on: September 20, 2017, 02:20:56 PM »
I'm new to this forum and hope y'all can help me out!

I'm not formally trained in billing, but I've been doing all of the billing at a small mental health clinic for 2 1/2 years. We rarely get clients with secondary insurance besides medicaid. My question is, when two insurance companies are used, which rate does the secondary pay?

Examples: we have a service that we bill at $480. Insurance company A's contracted rate pays $389 while company B pays $440. If A pays the full amount of $389, do I submit to B for them to cover the remaining $51 or would they not pay anything? If A pays $369 and patient responsibility is a $20 copay, does secondary cover or is copay always patient responsibility? If the rates were reversed (A pays $440, B pays $389) and A paid $420 with a $20 copay, would we submit to B for the additional $20 copay or would they deny because A has exceeded B's full rate? In that case, is it the responsibility of the patient to pay the $20 copay or not because primary already paid more than secondary would have? And I've heard that sometimes primary deductibles cover the secondary deductible, so in that case are we required to submit these even if they wouldn't pay anything?

I am our entire billing office and my boss is close to enacting a policy of not accepting secondary insurance because we just don't know these things. Thank you!

Michele

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Re: secondary reimbursement rates?
« Reply #1 on: September 20, 2017, 03:00:57 PM »
It varies from plan to plan.  Some plans only pay any patient responsibility remaining while others process according to their plan and pay anything over the amount paid by the first company.  You should always submit the claim to the secondary to see how they will process.  I wouldn't refuse the secondary, just bill the primary and then bill to the secondary with the primary eob to see what they will pay.
 
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PMRNC

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Re: secondary reimbursement rates?
« Reply #2 on: September 20, 2017, 04:37:38 PM »
It depends on the secondary carriers COB model. I always verify benefits with secondary to find out which method they COB with.

For your example you would most likely take the adjustment from the higher allowable.
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