Medicare Primary and Othr Ins Secondary

AthensCoder

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I just had a question for everyone. Is there a regulation set by medicare that says when they are the primary payer and there is a seconday payer (whos allowable is more) that we can only accept mcare payment minus any coins/ded? Does this make sense to anyone?

Example.

Mcare Primary Allw'd amt $552.94 and pays $442.36 coins: 110.58
BC secondary Allw'd Amt 992.25 and pd $992.25

From my understanding we only have to refund BC the overpayment of $442.36 (mcare pymt)

My office manager is telling me that we have to refund $881.67 the difference between BC payment minus Mcare coins.

Any help would be greatly appreciated.
 

dclark7

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This looks more like a coordination of benefits issue. If BC paid their full fee scedule they may think they're primary. Was a MSP questionaire done at the time of the visit? Before refunding any money I would get the COB straight, then look at who you have to refund.

Doreen
 

btadlock1

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This looks more like a coordination of benefits issue. If BC paid their full fee scedule they may think they're primary. Was a MSP questionaire done at the time of the visit? Before refunding any money I would get the COB straight, then look at who you have to refund.

Doreen
That's exactly right. You should call Medicare's eligibility line and check Medicare Secondary Payer status, to make sure that Medicare is supposed to be primary. Then you may have to have the patient call BCBS and/or Medicare and update their COB. Sometimes BCBS will pay like they're primary when they're not (usually not with Medicare, though), and if they did that and it caused an overpayment, you would actually refund the patient, not the payers. That's a rare occurance, though - you should definitely verify that they made the correct secondary payment amount before refunding anyone.
 

btadlock1

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Also...

Your office manager is right about the amount. You have to honor Medicare's allowable, regardless of what BCBS pays. The only amount that you can keep is the coinsurance amount - keeping any more would be equivalent to "balance billing", which is prohibited.
 
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