Wiki Anyone ever heard of a "Medicare Entitlement clause?"

[lisaevans]

We are receiving refund requests from Cigna (Accent Cost Containment Solutions) in which they state Cigna should not have paid as primary because the patient was entitled to Medicare Part B but did not choose to take the coverage. They state as follows:

If the individual is eligible for Medicare Part B but chooses not to take the coverage, the insurance carrier will process the claim as if the insured did elect Medicare Part B. The insured/patient would be responsible for the portion of the bill that Medicare would have paid had they elected the Medicare Part B coverage, or 80% of CIGNA's allowed amount.

Example: The patient has a $125 charge for an office visit. CIGNA's allowable amount is $100. If the patient did have Medicare Part B, Medicare would have paid $80; CIGNA would only be liable for the balance of $20. Since the patient was eligible and elected not to sign up for Medicare Part B, the patient would be liable for Medicare's portion. In the above example this would make the patient liable for $80. CIGNA's liability would be $20.

I understand their math, but I've never heard of such a clause in the 6 years I've been in this industry. When I called to verify this with Cigna, they gave me a completely different reason and would not confirm or deny a "Medicare Entitlement clause." This patient opted out of Part B coverage because she is employed and has group coverage through her employer.

Your thoughts? Thanks!!

 

[MarcusM]

Accent gets paid on funds they collect so they have a bias to getting money refunded no matter how convoluted the reasoning. Is Cigna the carrier for the employer funded group coverage plan? If so, you should call the patient and advise what is happening and in turn the patient needs to get HR involved. As an employer, I would be smoking hot to find out the company is paying thousands of dollars in premiums only to have the carrier pull this type stuff.

 

[ABonnell CPC]

Ive had this happen several times. I'm not sure why a patient would not want Part B, even if there is another type of insurance available. In most cases, I find out that the patient was misinformed on how to handle their coverage, by being told to opt out of Part B coverage. Does anyone else have more info?

 

[joecorinn]

If the patient chooses to have Medicare Part B, they have to pay monthly premiums for this even though they have commercial insurance through an employer which is primary. Maybe this is why some patients don't choose to have Medicare as secondary.