Wiki Medicare Secondary

[prusso]

I am trying to find the correct way to calculate the patient responsibility when Medicare is the secondary payor to a commerical insurance. It has always been my understanding that we can not collect more then the Medicare allowed amount. I have been getting a lot of conflicting information. If anyone can give me help on this it would be greatly appreciated.

 

[mhstrauss]

I am trying to find the correct way to calculate the patient responsibility when Medicare is the secondary payor to a commerical insurance. It has always been my understanding that we can not collect more then the Medicare allowed amount. I have been getting a lot of conflicting information. If anyone can give me help on this it would be greatly appreciated.

Your statement is correct. Even if the primary processes the claim and the EOB shows, for example, that the patient has a $40 copay, if the primary has already paid more than Medicare allows, Medicare will not pay, and the balance will be a write-off (our office does this as a Medicare Non-allowed adjustment). If the primary does not pay more than Medicare allows, but the difference is less than the copay amount, Medicare will generally pay (from what I've seen) 80% of that difference, then put the remaining 20% to patient responsibility. Anything left after that will again be an adjustment.

Does that make sense? Do you have any specific examples?

 

[prusso]

BCBS paid 293.72 and left 326.62 to pt respon, Then Medicare paid 264.76 and allowed 382.28 then left 112.12 to the pt respon. (The EOB showes they took into account the 296.72 payment in the contractual column). I am confused how this was calculated. This is a common type of payment in our office and we are confused if we are suppose to collect the pt respon from the Medicare eob or only collect up to the allowed amount of medicare allowed and refund medicare the difference. Does this make any since? Please excuse my lack of knowledge

After looking at what you said I think I understand what you are saying. If I am understanding you correctly then the pt responsiblity on the Medicare eob would be the correct pt respon and we would just adjust off the difference on the account.

 

[JoannaRupert]

I struggled with this also and after speaking to a Medicare Representative I was directed to:

?CMS Web site: Medicare Secondary Payer Manual (Pub. 100-05), Chapter 3, Section 30.4 and 30.5 (PDF, 228 KB)

This manual spells out that if the primary insurance pays more than the Medicare allowable, you cannot bill the patient for the balance due from the primary insurance. We follow the Medicare EOB for the patient responsibility.

 

[prusso]

I struggled with this also and after speaking to a Medicare Representative I was directed to:

?CMS Web site: Medicare Secondary Payer Manual (Pub. 100-05), Chapter 3, Section 30.4 and 30.5 (PDF, 228 KB)

This manual spells out that if the primary insurance pays more than the Medicare allowable, you cannot bill the patient for the balance due from the primary insurance. We follow the Medicare EOB for the patient responsibility.

So from what I am hearing we are adjusting the account to reflect what the Medicare EOB says is the patient responsbility. There are no additional calculations because we are following what medicare tells us to set pt respon as.

 

[mrsjehu]

Medicare is the final say as to what is owing to the patient. As long as the claim was processed correctly and you don't need to correct it. Whatever is on the Medicare EOB as patient responsibility would be correct.