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!!
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!!
Last edited: