Wiki 2nd carrier paying less than primary

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pochranek

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We have a patient where primary paid their allowed amount and the co-pay/co-insurance was submitted to the secondary carrier.

The secondary carrier came back stating the primary paid more than the secondary allowed amount and did not remit payment.

The question is:

Is the patient responsible or do we write the balance off as contractual.

Lunch is riding on this one. :)

Thanks!

Peggy
 
If you are also contracted with the secondary insurance, usually they will cover the copayment. But if their contracted allowable is less than the primary's, like we see with Medicaid, then you have to write off that copayment. It's a catch 22 because your contract with the primary states you are obligated to collect a copayment as part of that contract. Did the eob's designate the co insurance, copayments, & patient share? And the secondary had a zero patient share? You may want to re-negotiate the contract with the secondary plan
 
I disagree. I learned a few years ago that contractual allowance requirements apply only when the carrier is the primary payer. I cannot recall the source, so if anyone can give a source documenting that this is not correct, I will stand to be corrected! In the meantime, I will reach out to one of our provider reps to see if I can get an answer from her.
 
And this is why this forum is so good...different experiences, different opinions, and we are all working together to find the best possible solutions to a wide variety of problems.
 
Looks like no one is getting lunch yet! :)

I appreciate the responses and hopefully between we can find a more concrete answer.

I will reach out to the insurance carriers as well and post what I find out....however, they may not agree either....

This is why I love billing so much!
 
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