Payments > Patient Billing

HELP PLEASE! Primary/Secondary and Patient Responsibility

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Chiro Billing Collect:
I am completely confused on how to calculate patient responsibility when billing primary and secondary insurances (both Participating).

Do you think the secondary carrier calculates Patient Responsibility and enters correctly on their EOB? If not, can anyone provide an easy formula to calculate??

This is what I'm looking at: BCBS (primary): Allowable $45 (went towards deductible) - Patient Responsibility $85 - Paid $0
                                        1199-Aetna (secondary): Allowable $35 - Patient Responsibility $0 - Paid $35.

What would the patient owe, if anything?

Thank you in advance for your input.

Michele:
I'm confused on the BCBS.  If the allowable was $45 how did the Patient responsibility get to $85?

But in any case, if you are contracted with 1199 - Aetna then the patient would not owe anything.

Chiro Billing Collect:
Thank you for responding. I don't know if this is recent or I have just recently been noticing but BCBS has been listing non covered codes which should technically be adjustments as patient responsibility. That is also what had me even more confused. Thank you for the clarification.

I have read that we must honor both contracts of the primary and secondary. In other words, when calculating patient responsibility, basically use the lower of the 2 fee schedules minus what both insurances paid to find the total. Is that correct?

Michele:

--- Quote from: Chiro Billing Collect on October 10, 2017, 08:11:28 AM ---I have read that we must honor both contracts of the primary and secondary. In other words, when calculating patient responsibility, basically use the lower of the 2 fee schedules minus what both insurances paid to find the total. Is that correct?

--- End quote ---

Basically yes, because if you choose to bill the patient for the higher amount then you will be violating the contract with the other insurance.

PMRNC:

--- Quote ---In other words, when calculating patient responsibility, basically use the lower of the 2 fee schedules minus what both insurances paid to find the total. Is that correct?
--- End quote ---

No, actually, it is determined by the secondary's METHOD of COB. There are three methods. For your scenario it apperas as though it's a traditional COB model; this means the higher allowable determines the participating adjustment you take with two plans that the practice participates with.

We have a great COB manual which shows you how to calculate benefits in COB situations. It covers the three COB models, how to calculate the adjustments and patient responsibility as well as a sample for each COB model. You can purchase this at www.billerswebsite.com, right now it's in our "specials" area so click on specials from top menu. It's just $19.99.   If you are already a PMRNC member, the manual is free to download in our members only area within our Learning Center.

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