Wiki Billing with primary and secondary insurances

[sharonc2222]

Looking to verify the proper patient responsibility to bill them in the following scenario as well as the proper rationale.

Primary insurance is a high deductible plan through BCBS and allows $3000.00 to the patient's deductible for a patient's surgery on the $5000.00 billed charges. We do not participate with the primary insurance. It's a PPO plan. They were covered by the out of network benefits on the plan. BCBS says the patient's responsibility is the $5000.00.

Secondary insurance is Medicare and we do participate. Medicare allows $1000.00, pays out $800 with $200 coinsurance. Patient responsibility on remit says $200.00.

Do you bill the patient only the 20% coinsurance for $200?

Or do you bill the patient for $4200.00 ($5000.00 minus $800.00 paid by Medicare)

 

[kelroy123]

Does the Medicare EOB show processed as primary or secondary?

 

[sharonc2222]

Shows processed as secondary.

 

[csperoni]

If the 2ndary insurance (which you participate with), shows a patient responsibility of $200, that is what you bill the patient for. You would only bill the full remainder if you did not participate with either insurance.

 

[busterbrown2940]

I have a similar situation with billing. Do you know where I could find the answer to this question in writing for "official documentation?"

Thank you!!

 

[daedolos]

In the Medicare EOB, if the write-off plus the amount payed by Medicare plus the amount designated by Medicare to be patient responsibility is equal to the full amount of the surgery, then the full bull is accounted for by Medicare and you have no other recourse to bill other than the coinsurance. Out-of-network claims are unfortunate for the provider in this case.

Peace
@_*

 

[sharonc2222]

Documentation?

One of our providers feels differently saying that they should still be responsible for the amount the primary insurance designates at least for the deductible. I tried looking on Medicare's website for secondary payer instances, but there aren't any scenarios where the primary insurance is not participated in. Can anyone provide a link to documentation that I can show that says it ok to bill for just the Medicare coinsurance? Thanks everyone!

 

[KN]

"They were covered by the out of network benefits on the plan", so did the patient have out of network benefits?

 

[sharonc2222]

Yes the patient had OON benefits under the primary insurance.

 

[michellepilcher]

https://www.aarp.org/content/dam/aa...lance-billing-and-private-contracting-ppi.pdf

The vast majority of physicians—about 95 percent—are “participating providers,” which means they agree to accept Medicare’s approved payment amounts as full payment for the Medicare-covered services they provide for all Medicare patients they see. Patients may be billed for any Medicare cost sharing (such as deductibles, copayments, and co-insurance) that applies, but cannot be balance-billed for additional charges. If the patient has supplemental private insurance, it may cover some or all of the cost sharing.

You can only balance bill if you do not participate with Medicare but cannot exceed 15% of the Medicare allowed amount. You agree to accept the allowed amount when you sign participation papers.


https://www.kff.org/medicare/issue-...e-patients-when-receiving-physician-services/

 

[sharonc2222]

Documentation Found

Thanks everyone for your replies. I finally found an article that speaks to the primary payer with MSP and actually states not to bill, which is what I needed to show. See link below and specific excerpts:

"Providers often ask if the beneficiary is responsible for the primary payer’s deductible, coinsurance and/or co-payment amounts. The beneficiary is not responsible for these amounts because you would have billed Medicare for these amounts when submitting the MSP claim".

https://www.ngsmedicare.com/ngs/por.../?clearcookie=&savecookie=&LOB=Part B&REGION=