Payments > Patient Billing

which allowable???

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rdmoore2003:
ok, I am a little confused.   I asked this question before and was answered.
If you have a contract with both insurances, primary pays and then pt has a copay or say partial deductible, we of course file to secondary.  but because of the contracts, we are to use the contracted allowed amount.  Was this information not correct.

another ex.     contracted with say medicare primary and bcbs secondary.   medicare allows 50.00, pays 45.00, pt responsible for the 5.00.   send eob and claim to bc they will pay the 5.00 per the primary eob and nothing else. 

Its like you have met your deductible, bc is primary, and pays 100% of allowed amount.  You cannot then turn around and send to secondary of say Aetna.  You have a contracted rate with primary that paid 100%.   If you send to secondary rather in or out of network, isnt this considered double dipping?    Something seems a little fishy, however, I did hit my head this morning.......

dekenn:
Not double dipping, but if the insurances have different allowables, depending on their payment rules, they could pay additional money, up to their allowable, but not more than 100% of the BILLED amount.  You would bill the same amount to both insurances, (you don't set up a new claim for the secondary, they get the same claim, same billed amount, just marked secondary, and sent with the primary eob attached.)
This does happen sometimes, with commercial insurances...
my question however is can you bill the patient the higher "patient liability"??
Example:
Billed Amount:   99203  150.00
                      20550  125.00
                      J1094    22.50
                      99213   100.00
Primary Insurance:      
                          Allowed      Paid
99203                   60.00        48.00
20550                   50.00        50.00
J1094                    11.25         9.00
Patient Responsibility:   14.25
99213                   35.00          28.00
Patient Resposibility:   7.00

Secondary Insurance:   
                            Allowed        Co-Ins          Deductible                  Other Carr       Paid
99203                     111.40         11.14              0                                48.00       52.26
20550                       71.40          7.14              0                                50 .00      14.26
J1094                        4.68             .47              0                                 9.00           0
Patient Resposibility (shown on eob):  18.75

99213                     71.96             4.55            26.50                           28.00          12.91
Patient Responsibility (shown on eob):  31.05


SSSSOOOOO....  According to the primary insurance, patient liability is 21.25, but according to secondary insurance, patient liability is 49.80.    Which do I go by?? ??? ??? ???

Michele:
When you submit a claim to a secondary you are not just submitting what the primary didn't pay, you are submitting the entire claim (original charges just like were submitted to primary) but with payment information from primary.  I think that is where the confusion is coming in.  You are not submitting just the balance or patient responsibility after the primary.  You are submitting the entire claim (with payment info).  It's definitely not double dipping as when all is said and done provider should not have been paid more than the billed amount.  (unless the secondary is a private plan, which is paid for by the patient and they don't go by the primary payment info - which is very rare)

Michele:
dekenn,

    I believe Linda is right and that you go by the insurance with the higher liability.  Although I believe most providers do the opposite because they believe they are breaking the contract with the primary carrier.  But the claim was submitted to the secondary with the primary payment info, they processed and calculated (based on the provider's contract) what the patient liability is after taking both payments into consideration.

Michele

PMRNC:

--- Quote ---I believe Linda is right and that you go by the insurance with the higher liability
--- End quote ---

Well, it's the higher allowable.   That's the COB rule, to take the higher allowable of the two plans, even if there were a tertiary, again you would take the higher allowable.

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