Patient Billing When Medicare Is the Secondary Payer
When Medicare acts as a secondary payer—that is, when another insurer, such as workman’s compensation, is primary—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.
If the amount paid by the primary payer is equal to, or more than, the amount the patient owes, as determined by Medicare, and you know that the deductible has been met, you do not have to submit a claim to Medicare (Medicare will pay nothing). You still may wish to file the claim with Medicare, however, because 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 can benefit from filing the claim with the Medicare secondary payer, while a small practice with small outstanding amounts may not find this as cost effective.
If the deductible is not yet met, send a claim to Medicare. Medicare will make no payment, but the amount will be applied to the patient’s deductible.
For more information on Medicare Secondary Payer (MSP), see the CMS webpage.
—Delly Parham, CPC, AS