Wiki COB Question for In Network for both Insurances

[terhufen]

Hello,
We are contracted with UHC which as primary insurance assigned $700 to patient deductible. The secondary we are also contracted with, and they assigned only $300 to patient deductible. Which plan do we honor? How much does the patient owe us? The $700 or the $300.

 

[thomas7331]

Payer contracts usually specify that you may not bill the patient more than the allowable amount, minus any payments made by the insurance. So in order to comply with both of your contracts, you would need to accept the lower of the two contractual amounts as payment in full. If the secondary plan has coordinated benefits correctly, their EOB should tell you how much you may bill the patient after considering how both plans have processed the claims.

 

[SharonCollachi]

We only allow the primary plan to "drive the bus" - they are the ones in charge. If the primary says the patient owes $700, then that's what they owe. If their secondary insurance declines to pay anything, the patient still owes $700.

(unless Medicare or other governmental plan is involved)

 

[terhufen]

Thank you both for answering. We have usually only allowed the primary plan to "drive the bus"...but now that we have contracts with both plans, we are not sure which answer is the compliant answer. The plan does state in our contract that we cannot bill patient for more than the allowable amount. But the primary should be the plan that sets that allowable, and if the secondary does not pay the allowed set by the primary, why should we have to accept the lower amount that the secondary set?

 

[thomas7331]

Thank you both for answering. We have usually only allowed the primary plan to "drive the bus"...but now that we have contracts with both plans, we are not sure which answer is the compliant answer. The plan does state in our contract that we cannot bill patient for more than the allowable amount. But the primary should be the plan that sets that allowable, and if the secondary does not pay the allowed set by the primary, why should we have to accept the lower amount that the secondary set?

I am not an attorney, but it seems pretty plain to me that if you have signed a contract with a payer wherein you have agree to accept their allowable as payment in full, but then you bill a patient more than that amount, then unless there is a clause in the contract that allows this in the case of a secondary payer, you are likely in violation of your agreement. If you are contracted with both payers, you have to be compliant with both contracts by not exceeding the allowable in either case.

If you are being challenged by the patient or the payer on this, it might be best to review the contracts and if the answer is not clear one way or another, then you may want to consult your practice's attorney for advice. Of course, if you consider the cost of getting an attorney involved and/or trying to negotiate a contractual dispute with a payer, that could well exceed the $400 difference in payment that you are disputing here, so it might end up being more cost-effective to just let this go.