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

dec-clearance-sale

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

One Response to “Patient Billing When Medicare Is the Secondary Payer”

  1. Michele Price says:

    We are having extreme difficulty with Medicare putting Workers compensation and Auto insurance as primary when the primary has not been their primary for years. We cant bill the primary due to the claim having personal information on it that is clearly not workers compensation or auto related in nature. We feel that billing the primary is in violation of patient privacy due to the diagnoses and billing these types of claims knowing they are not auto or workers compensation seem wrong to being with. We leave the primary on the claim and bill Medicare as the secondary with a CO22. Of course, they ALWAYS deny for not being the patients primary. We have had the patients go through Medicare and fill the letter out with the termination date on it and still we don’t receive a payment. What do we do in these cases?

Leave a Reply

Your email address will not be published. Required fields are marked *