Wiki Commercial Vs. Medicare Allowable Rates

[IshratKhurshid]

Can someone please answer this question?
Humana is paying 78% of the Medicare allowable on a J code. We are already billing the patient the difference between Humana allowable and what Humana paid. Do we have also need to bill the patient the difference between Humana allowable and Medicare Allowable?

Here is an example;

Humana:
Allowed-------Paid-------Patient Resp.
$862.70-------$680.33-------$182.37

Medicare:
Allowed-------Paid-------Patient Resp.
$999.46-------$799.57-------$199.89


We billed the patient $182.37. Do we need to bill the patient $199.89 instead?


Thanks!

 

[cgaston]

If you are a participating provider with Humana your contract states you will accept their allowed amounts, so you should only bill the patient $182.37.

 

[CodingKing]

The Medicare payment amount looks way off for Medicare secondary payer. They would never pay more than what is left after primary payment.