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Help with secondary ins. billing

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alaughlin:
I am a biller for a physical therapy office and I cant get a patients secondary to pay on his claims. This patient had reached his medicare cap and has a secondary ins. that he pays for full coverage.  The secondary ins. is telling me that I need to rebill Medicare saying that these charges are a medical necessity.  I called Medicare and was told I did not need to rebill them but  to send the Medicare Eob's to the secondary ins. showing that the charges are the patients responibility and the secondary should pay for these claims.  Can anybody help?

PMRNC:
What is the exact denial on the Secondary EOB, some policies will not cover charges that Medicare doesn't or will not pay if they max out a benefit with Medicare. You might need to research the secondary policy.

Pay_My_Claims:
I agree with Linda. It really depends on why the 2ndary denied. Most supplemental plans will only pay if Medicare pays. 2ndary plans will consider charges after medicare if it is allowed under their plans. Example: Client received a PWC in 2006, per Medicare he isn't eligible until 2011 (reached max), however we have authorization from his 2ndary plan (Cigna) that will pay even though Medicare denied. Had this been AARP, they would not pay simply because they follow Medicare guidelines. If they deny, so does AARP.

Michele:
I have a similar situation.  It sounds like they are saying the secondary is insisting they appeal the Medicare denial.  With the Medicare CAP you can't.  I would resubmit to the secondary with a cover letter explaining the Medicare CAP and that it is NOT appealable (correct grammer!?!?!).  Print out the page from CMS regarding the PT/OT/ST CAP and attach it.  They just need an education.  47% of rejected claims go unappealed so they have a good reason to deny the first time.

Michele

alaughlin:
Here is what the secondary said, " We have received a Medicare summary notice that indicates the patient has met Medicare's outpatient therapy cap. If you consider these charges medically necessary, please resubmit to medicare with the correct coding and documentation.  Once Medicare has mad their determination, we can then consider these charges for payment.  If you choose not to refile with mMedicare, We will consider the charges as not medically necessary."

Medicare is telling me I do not have to refile with them.  Thanks in advance for any help.  Alaughlin

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