Optometry Coding & Billing Alert

Published on Tue Feb 22, 2005 PDF

Question: A patient's primary insurer is Medicare, and she also has a secondary insurance. Medicare has paid its portion, and the explanation of benefits shows patient responsibility as the amount left over. Medicare did not forward to the secondary insurance. Are we responsible for filing the secondary (as the patient believes), or can we bill the patient and have her submit to her secondary?


Arizona Subscriber

Answer: It might be in your practice's best interest to file the claim on your patient's behalf. Many statements that patients receive from their optometrists do not include all the information an insurer requires. This may slow down reimbursement if the patient tries to file the secondary himself - leaving you with a disgruntled patient. It will be easier for the secondary carrier to pay the difference if they receive an official CMS-1500 form.
 
First step: Call the secondary company and make sure it hasn't already received the claim from Medicare. If the company hasn't received the claim, the representative can tell you the carrier's preferred method of receiving the info. Most want a new claim form and a copy of the Medicare EOB.

Strategy: If you have repeated trouble with a particular carrier, file a complaint with the insurance board. Insurance companies don't have to respond to providers' inquiries, but they do have to respond to the board if they wish to continue doing business in the state.
 
Compile a list of claims the carrier claims it never received. Photocopy the front of any envelope you sent, showing the address and postage or the meter stamp with the date. After you collect about 10 of these, you should have a start on the documentation the board will require to justify your complaint.