Payments > Insurance Payments

Medicare Secondary Payer



Do you have any problem getting paid by Medicare(or other carrier) as secondary payer for a procedure whenever the primary payer ( group health plan) allowable is above the Medicare allowable?
Here is an example:
Primary Allow= $420
Primary paid= $336
Patient responsability= $84

Medicare Allow= $330

So Medicare as a secondary payer will denial the $84 payment because his allowable $330 is > to $420?? I saw this question with others billers and I am confused because I will offer copays and deductibles calculations+cob services to my clients and I want to make sure that I am doing things right.

From the books I explored and medical billing courses I have taken, the secondary payer would pay the $84 from the $330 unless there is any deductible either copayment the patient would be responsable for.

Thank you for telling me what you think.

Sorry, I was out of town last week. 

Medicare secondary payor is not an easy explanation.  It seems in my experience that they pay the balance after the primary payment up to the Medicare allowed amount.  Unless the primary didn't make payment due to deductible, or non covered service.  Then Medicare seems to pay 80% of their allowed amount as if they were prime.   

In your example, I would expect Medicare to pay $0 as you stated.  I also would expect the Medicare eob to state that the patient responsibility is $0 as well, since the primary insurance paid more than the Medicare allowed amount.

Just when you think you've got it straight, they do it differently!

Michele :)


My name's Kristy from MDO billing agency. I'm interested in this topic and would like to ask: In this case, MED eligible paid in full, and MED EOB shows PT RESP $0, should I adjust $84?


It is really difficult to be sure without seeing the actual eobs, but if the Medicare EOB shows the patient responsibility as $0 then you should adjust off the $84.  I only hesitate since I cannot see both of the eobs in front of me.


Thank you for your response :) yes, pt resp is 0$ and I will adjust it.


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