Wiki Medicare secondary


Sugar Hill, GA
Best answers
I need some help with this. If I see a patient who has an OUT OF NETWORK carrier as primary and Medicare as secondary (I am par with only Medicare), am I required to submit to medicare even if the patient should be responsible in full for the billed amount according to the primary carrier?

I have asked medicare on numerous occasions what to do and I get a different answer from each person. Patients also call and get different answers and yet I am left stuck in the middle and confused.

Example:A patient has United Healthcare primary and Medicare secondary (for all purposes of this there are no deductibles and coinsurances involved)

UHC is billed $400.00 and paid $200.00. The patient is responsible for the other $200.00 as per the EOB. What is the right thing to do?

A) have the patient pay the $200.00 difference and they need to seek reimbursement from medicare on their own since we are following the primary carriers guidelines

B) I submit to medicare and the patient would owe the difference between what medicare paid and the $200.00 balance from UHC (but the mcr eob says there is no patient responsibility)

C) The patient pays the $200.00 and I somehow sumbit for the patient to be reimbursed by medicare.

D) another suggestion

I have looked for documentation without much success, the reps at Medicare just say to look in the manual, and all I see is "how to" submit a claim with no information about being out of network with the primary carrier.

Please help.
Bill according to the patient's primary insurance in or out of network. The balance after the primary pays can be billed to Medicare whether or not the primary is in network or not. It is better for the patient to be in network or at least have insurance authorization for out of network physicians.
Im actually trying to avoid having to send it to Medicare secondary. In the past they pay incorrectly and its causes refunds for me and the patients being confused by multiple Medicare notices being sent to them.
Most of the patients are seen in the hospital so authorizations are not an issue here. How can Medicare not be able to give me consistant answers?