HELP PLEASE! Primary/Secondary and Patient Responsibility

[Chiro Billing Collect]

I am completely confused on how to calculate patient responsibility when billing primary and secondary insurances (both Participating).

Do you think the secondary carrier calculates Patient Responsibility and enters correctly on their EOB? If not, can anyone provide an easy formula to calculate??

This is what I'm looking at: BCBS (primary): Allowable $45 (went towards deductible) - Patient Responsibility $85 - Paid $0
                                        1199-Aetna (secondary): Allowable $35 - Patient Responsibility $0 - Paid $35.

What would the patient owe, if anything?

Thank you in advance for your input.

[Michele]

I'm confused on the BCBS.  If the allowable was $45 how did the Patient responsibility get to $85?

But in any case, if you are contracted with 1199 - Aetna then the patient would not owe anything.

[Chiro Billing Collect]

Thank you for responding. I don't know if this is recent or I have just recently been noticing but BCBS has been listing non covered codes which should technically be adjustments as patient responsibility. That is also what had me even more confused. Thank you for the clarification.

I have read that we must honor both contracts of the primary and secondary. In other words, when calculating patient responsibility, basically use the lower of the 2 fee schedules minus what both insurances paid to find the total. Is that correct?

[Michele]

I have read that we must honor both contracts of the primary and secondary. In other words, when calculating patient responsibility, basically use the lower of the 2 fee schedules minus what both insurances paid to find the total. Is that correct?

Basically yes, because if you choose to bill the patient for the higher amount then you will be violating the contract with the other insurance.

[PMRNC]

In other words, when calculating patient responsibility, basically use the lower of the 2 fee schedules minus what both insurances paid to find the total. Is that correct?

No, actually, it is determined by the secondary's METHOD of COB. There are three methods. For your scenario it apperas as though it's a traditional COB model; this means the higher allowable determines the participating adjustment you take with two plans that the practice participates with.

We have a great COB manual which shows you how to calculate benefits in COB situations. It covers the three COB models, how to calculate the adjustments and patient responsibility as well as a sample for each COB model. You can purchase this at www.billerswebsite.com, right now it's in our "specials" area so click on specials from top menu. It's just $19.99.   If you are already a PMRNC member, the manual is free to download in our members only area within our Learning Center.

[Chiro Billing Collect]

Thank you. I purchased the manual. This way was closest to how I have been calculating patient responsibility up to this point. It does, however, conflict with the statements above that both contracts must be honored. If that were the case, then patient would have $0 patient responsibility.

When I calculate with higher allowable as stated in the manual, the patient is responsible for a balance.

I am still unsure as to which is the correct answer but appreciate both of your answers.

[PMRNC]

In other words, when calculating patient responsibility, basically use the lower of the 2 fee schedules minus what both insurances paid to find the total. Is that correct?

Yes, I had an idea it would.

This is what I'm looking at: BCBS (primary): Allowable $45 (went towards deductible) - Patient Responsibility $85 - Paid $0
                                        1199-Aetna (secondary): Allowable $35 - Patient Responsibility $0 - Paid $35.

You did not include the total charges, and in your example the allowable from primary  was $45 but patient responsibility was $85 and your secondary allowable was $35 with them paying $35 .    The patient responsibility from primary carrier of $85 is throwing me as the allowable's from both are so way UNDER that I can't really determine anything w/out knowing the actual charges.

[Chiro Billing Collect]

BCBS lists charges which should actually be adjusted off as patient responsibility which is why the PR was greater than the allowable. I am not sure why they have been doing this on our EOR's as we are participating but I am going to disregard that and adjust it off. Here is what it should be:

BCBS (primary): Total charges $115 - Allowable  $45  - (went towards deductible)- Patient responsibility - $45 - Paid $0 <Benefits include $500 deduct which isn't met and $45 max per visit>

Aetna (1199-secondary): Allowable $35  - Patient responsibility $0 - Paid $35 <Benefits include $0 deduct  $0 copay>

According to your method, the patient would owe $10 I believe. If I was to honor both contracts or follow the lower fee schedule, the patient would $0.

[PMRNC]

BCBS lists charges which should actually be adjusted off as patient responsibility which is why the PR was greater than the allowable. I am not sure why they have been doing this on our EOR's as we are participating but I am going to disregard that and adjust it off. Here is what it should be:

BCBS (primary): Total charges $115 - Allowable  $45  - (went towards deductible)- Patient responsibility - $45 - Paid $0 <Benefits include $500 deduct which isn't met and $45 max per visit>

Aetna (1199-secondary): Allowable $35  - Patient responsibility $0 - Paid $35 <Benefits include $0 deduct  $0 copay>

According to your method, the patient would owe $10 I believe. If I was to honor both contracts or follow the lower fee schedule, the patient would $0.

BINGO.. you got it.  

BUT.. on a side note.. I really want to know why of $115 the primary only allowed $45.

[Michele]

According to your method, the patient would owe $10 I believe. If I was to honor both contracts or follow the lower fee schedule, the patient would $0.

BINGO.. you got it.  

So now I'm confused.....which is correct?

[PMRNC]

$10 as they owe the copay from secondary

but again.. curious .. why was allowable only $45 on $110 charge?

[Chiro Billing Collect]

The secondary benefits include $0 copay and they also stated that the patient should not have any financial responsibility on the EOB and even when I called and asked them which COB method they used to process the claim.

Patient's plan only allowed a maximum of $45 per chiropractic visit. We billed 3 services: Spinal manipulation-->billed $50, allowed $36, mechanical traction---> billed $25, allowed $9, and also billed extra spinal adjustment $40, allowed $0 which we thought was on the secondary's fee schedule and they would pick it up as an allowable expense. That is why there is a big difference in total charge and allowable.

Michelle, I'm with you! I understand the calculations now but there is still conflicting answers on which is the correct fee schedule to follow.

[PMRNC]

Somewhere there is a mistake in the original post. The PRIMARY allowed $45 but says patient responsibility is $85 so there is a discrepancy there. Since you say full charges were $110, I'm assuming that the allowable would have been $110 with $45 being applied to deductible leaving patient with $85 balance. (Again, I can't confirm this because there is a big discrepancy with the allowable and the primary payment).   Then.. again going by your original post, secondary only allowed $35 and paid $35. 

I don't want to assume in case you made an error in your original post, but there is def a problem with primary EOB with them allowing $45, applying $45 to deductible and saying patient is responsible for $85. That is where the problem lies.

Total charges $110: BCBS (primary): Allowable $45 (went towards deductible) - Patient Responsibility $85 - Paid $0
                                        1199-Aetna (secondary): Allowable $35 - Patient Responsibility $0 - Paid $35

Adjustment is $65  (higher allowable of $110-$45)    Primary payment $0. Secondary Payment $35

[Chiro Billing Collect]

In my second post I stated that BCBS calculates non-covered charges as patient responsibility therefore they included the extra spinal charge of $40, plus the deductible charge/max per visit of $45 which went towards the deductible and that equals $85.

We are adjusting off the $40 extra spinal charge. Neither insurance considered it as an allowable expense therefore it should not be patient responsibility as per NAIC. Either way, the primary insurance only allows a max of $45 per visit no matter what the total charge. That leaves the following calculations I most recently laid out.


BCBS (primary): Total charges $115 - Allowable  $45  - (went towards deductible)- Patient responsibility $45 - Ins. Paid $0 <Benefits include $500 deduct which isn't met and $45 max per visit>

Aetna (1199-secondary): Allowable $35  - Patient responsibility $0 -Ins. Paid $35 <Benefits include $0 deduct  $0 copay>

[Michele]

$10 as they owe the copay from secondary

But doesn't that violate the contract with Aetna (1199)?

This is a great topic.  It isn't something that comes up terribly often but when it does it is always a debate.  I know it goes by COB method but I'm still hung up on the fact that the secondary is saying $0 PR.