Wiki Filing Secondary Claims

[nbohm]

This is something that comes up from time to time and trying to find out some more information or what others have determined.

1) Is a provider obligated to file secondary claims (if they don't automatically crossover)?

2) And if so, what obligation is it of the provider to adjust off these amounts if they are not payable...it is not always clear in a contract to say if coordination of benefits applies and at times as a billing company we do not have access to this information. It just seems like so many come back primary paid more and the provider is out money which we feel at times is a patient responsibility since we filed the secondary as a courtesy for them.

If this is how it is then we just have to explain that to the provider but where can we get any kind of documentation or does anyone know something that we can get to support this either way? Any guidance at all would be appreciated.

 

[philipwells]

The only insurance we ever make adjustments for as far as secondary insurance goes is Medicaid (Primary paid more than secondary type), and Medicare secondary, will occasionally have small change between .20 cents to a dollar to adjust.

Most of your other commercials - UHC, Aetna, Cigna, Healthspring will never have secondary adjustments. They either pay the coinsurance or they leave it as patient responsibility.

When it comes to obligation, it's a courtesy to file secondary if the provider is not credentialed/contracted but in the case were the provider is contracted with the insurance then he/she is contractually obligated to file the insurance.

Most remits will tell you what to adjust and what is patient responsibility. CO (contractual obligation w/o) and PR (patient responsibility)

Hope this helps some.

 

[nbohm]

Was looking for something like this to help us in confirming what we thought so yes this does help and thanks for taking the time to respond!!

 

[CodingKing]

It just seems like so many come back primary paid more and the provider is out money which we feel at times is a patient responsibility since we filed the secondary as a courtesy for them.

If you are contracted with the secondary insurance, in the end it doesn't really matter who submitted it. If the secondary doesn't pay anything because the contracted allowed amount is lower than what primary paid. You cannot balance bill the patient. Even if the primary left a patient responsibility. You don't get to ignore the contractual liabilities of the secondary just because you like the rates from the primary insurance better. COB is really there to help the patient save money. Sometimes the practice gets lucky but sometimes not.

Example
Primary allowance is $1,000
Primary pays $500 and leaves $500 coinsurance or deductible.

Secondary which you are contracted with allows $400 and they pay $0

You have to write off the remainder. In this example you made $100 extra since primary paid over and above what your payment would have been if the patient didn't have that primary insurance.

What happens in this circumstance if you bill the member. You may get a not so friendly call from the secondary carrier and the patient. Or if you do it too often you may hear from the carriers legal department or worse an audit on all the business you have done with the secondary carrier.

 

[Cindy Akkerman]

Secondary Claims

I have only seen a few where the 2nd does not pay because the primary paid more. I would check those carriers and verify the reimbursements. There may be some issues with the claim edits. I would make sure that i follow up on these to determine if they were paid correctly.

 

[ewilliams941@gmail.com]

Filing to Secondary or Tertiary

When it comes to obligation, it's a courtesy to file secondary if the provider is not credentialed/contracted but in the case were the provider is contracted with the insurance then he/she is contractually obligated to file the insurance.

Hope this helps some.

This was exactly what I was looking for in this thread ... I wondered why (as a coder) our CBO would not bill claims to Tertiary (usually VA claims) to the insurance. They always claimed it would only be a courtesy if they did. Now I understand better! Since we are not contracted with VA Thank you!