Staying in Compliance When Medicare Is the Secondary Payer

By Delly Parham, AS, CPC-A

Billing Medicare when another payer is primary can be confusing, causing providers to improperly bill patients or write off the balance. Here are some steps to help you stay in compliance and receive payment:

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  • You cannot bill the patient for any amount unless the secondary claim has been filed with Medicare, and Medicare determines the amount owed by the patient.
  • Don’t submit a claim to Medicare if the patient has met his or her deductible and the amount paid by the primary payer is equal to or more than the amount the patient owes.
  • If the patient’s deductible is not yet met, submit the claim to Medicare anyhow. While Medicare won’t pay, it will apply the patient’s payment to his or her deductible.

Even if you are satisfied that the amount paid by the primary payer is more than the Medicare allowed amount, and you will not bill the patient, you may still wish to file the claim with the Medicare secondary payer. If the primary payer later determines that it is not the primary payer and requests a refund, the claim will be on file with Medicare and will not be denied for timely filing.

It may cost less to forego filing the claims with Medicare than the amount that may be written off due to timely filing. A large practice with large outstanding amounts could benefit from filing the claim with the Medicare secondary payer, while this may not be cost effective for a small practice or for small amounts outstanding.

There may be specific guidelines for insurances such as automobile or workers’ compensation in states with no-fault. There may be some in Veterans Affairs or other government insurances. Comply with the requirements of these payers prior to filing with Medicare as Secondary Payer.

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