Payments > Patient Billing

HELP PLEASE! Primary/Secondary and Patient Responsibility

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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.





--- Quote ---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
--- End quote ---

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:

--- Quote from: PMRNC on October 16, 2017, 06:48:53 PM ---$10 as they owe the copay from secondary :)


--- End quote ---

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.

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