Medicare Deductible

[Christine_1]

Thanks in advance for any help. Still pretty new at this so any help is appreciated.
Medicare billed= $136.00
Medicare paid= $0.80
Medicare deductible= $135.20

claim crosses over to Healthlink

Healthlink paid= $74.79
Healthlink copay= $15.00
Healthlink adjustment=$46.21

I didn't understand why we would have to take a contracted adjustment. HLink says because in a case like this they become primary payor. Also, that if they had 100% of the benefits they would pay at 100%. Help I dont understand.

[thatcuteblonde]

I agree with you it is strange that they are discounting the deductible. Normally the secondary will allow the difference between the Medicare allowed amount and what Medicare has paid. From what you've said it appears that Healthlink is a secondary not a supplement and they are handling it as though they were the primary carrier, which would be fine if Medicare had denied it but because they applied it to the patient's deductible, it does seem unusual. I would suggest calling Healthlink and making sure they understand the charges were applied to the patient's Medicare Part B deductible and not denied. If you think they've made a mistake but they are insisting everything was processed correctly try this;
Hang up and call up Healthlink back. Ask to verify benefits for your patient. Tell them Medicare is primary and verify they have that on record. Find out if they act as a secondary or a supplement. Then ask if they will cover the Medicare Part B deductible and ask how that is handled. Find out if they consider charges based the Medicare allowable or if they disregard Medicare entirely and process based on their contracted rate in cases of denials and decutibles. If they tell you they will consider charges based on the Medicare allowed amount, pay their percentage and the remainder is the patients responsiblity, you can bring up the fact that they handled it differently with this particular date of service and you should be able to get it reprocessed.
Hope that helps,
Randi   

[Michele]

Hi,
   Thanks for your help Randi.  That was a very detailed answer.  I just wanted to add that if the Healthlink plan is a group plan, not a Medicare supplemental policy, they don't follow medicare, they process based on their plans guidelines.  If you are in network with them, you have to accept their processing even if it is different then Medicare.

Hope that helps
Michele

[Christine_1]

Ok, here's an update. Talked to our HLink rep today and she said the only reason she can she this happened is last year member was sent form for additional insurance information. They filled form out saying they have no other coverage. So HLink was acting as primary. She was going to send it back to processing and let them now medicare was primary. I am at home so I don't remember how the claim was filed with HLink, but either way if it was a automatic crossover from medicare or if it was a paper claim sent with medicare eob attached, wouldn't that be enough for them to know medicare is primary?

[Michele]

If their records show they are prime, and a processor who is possibly new, or just doesn't want to be bothered gets the claim, they might just ignore the attached Medicare EOB.  It's a shame that it happens that way, but it does happen.  Anyway it's great that you got to the bottom of it. 

Michele

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