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SirCodesAlot07

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Stuart Sailfish Chapter
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I have a patient that came in and had 4 procedures performed. Patient has UHC primary and Medicare secondary. Our UHC only allows 3 procedure codes. The first 3 codes were paid by UHC and the last one was denied CO-97. We then sent the claim to Medicare for the UHC coinsurance. They paid the proper coinsurance amounts for the first 3 codes but then paid the 4th code as well, even though UHC denied it since they only pay 3 codes. I have reached out to both UHC and Medicare. They both say they processed the claim correctly. I am trying to figure out if I should refund Medicare...do I bill the patient for the 20% coinsurance for the 4th code Medicare allowed? I am not sure if we are really entitled to the Medicare payment on the 4th code since we are contracted with UHC and they only pay for 3 codes. Thanks for any insight.
 
If your office is contracted with both UHC and Medicare you would:

  • Accept the payment from UHC and Medicare for the first 3 codes and following the guidelines for co-pay or deductibles as noted after a review of both EOB's


  • For the 4th code you can keep the payment from Medicare even though UHC denied it as inclusive.


  • However, if UHC showed no patient liability on this code then based on your contracted you should not bill the patient for the Medicare co-pay amount as this is in contradiction to the UHC contract.
UHC states not payable and not the patient liability (Patient owes -0-)
Medicare states it is payable and shows 20% as patient responsibility (Patient owes 20%)

In this case you would follow the contract that most benefits the patient and adjust the 20% as inclusive per UHC. as they show the patient is not liable for the code.
 
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