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Medicare secondary OTAF


Question: My provider wants to become in network with Aetna. The reimbursement with Aetna is awful. We have a client with Aetna primary, Medicare secondary. Previously we didn't have to calculate the OTAF because we were non-par provider. My question is, once we calculate OTAF, will Medicare consider up to their allowable, or just up to what Aetna will allow.

Ex: k0011 we bill 5000, Aetna allows 2000 Medicare allowable is 3700
Aetna pays 80% after the clients 500 ded. so they pay 1200 Medicare would have paid 2960

Will the calculation be 2000-1200 = 800, and that is what Medicare will pay 800.00???

I answered you on the other forum but it's a good question so I'll copy my response here:

When a primary payer allows less than the billed amount and the provider is contractually obligated to accept that amount as payment in full then the allowed amount is the OTAF amount.

When the allowable billed amount is $100, the primary insurance pays $45, the provider OTAF amount is $50, then Medicare would pay $5 as secondary.

I always have to look this up myself.

LOL, yes I got them both, so my analysis was correct. I have to give this information to the owner to determine what he is going to do. I TOLD him previously to NOT become par with Aetna. The reimbursement sucks!!

Hello Pay My Claims,

If you are out of network with Aetna and you are participating with Medicare, you will get reimbursed by Medicare at the participating provider allowable.  However, if you're par with Aetna and they are primary, you are at the mercy of Aetna as far as reimbursement.  Your Secondary payor (medicare) will follow suit.  If Aetna reimbuse more than what Medicare allows, you will get zero from Medicare.  

I hope this helps,


Thanks, I wanted to make sure I was correct before sending my report to the owner of the company. I knew posting here would get me some assistance. We are non-par, but she has an epo policy with no OON benefits. We were using another provider to bill, but thank God that didnt happen. I tried to tell him to walk away from it and refer her to a network provider. He asked my opinion once about Aetna and I said NO. The first problem with this case was waiting until she changed insurances before proceeding. She had BCBS which we are OON with also, but she had medicare 2ndary. She hadn't met her oOn deductible, but some nut said wait, now we are in a messy position. We want to help her, but her 30,000 chair will only pay out 9,000  :o


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