Patient responsibility after Medicare and other secondary

Manenaj

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Local Chapter Officer
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1
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Does anyone know from a billing aspect, when primary, Medicare, determines a charge to be patient responsibility (PR 96), secondary denies as non covered per contract, therefore not patient responsibility. ..is this still patient responsibility due to Medicare rule?
 

Coding Chick

Networker
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27
Location
Las Vegas, NV
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In general, most offices only contract with the 1st insurance, having a secondary is not a guarantee of payment. As stated, the 2ndry is denying for not being allowed in the contract. I would bill the patient as directed by Medicare.
 

trarut

Expert
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339
Location
Columbus, OH
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I have to respectfully disagree with part of Coder Chick's answer. Our contracts do not distinguish between primary and secondary responsibility and we are held to the terms of our payer contracts for secondary claims. If a secondary claim denies as a contractual obligation, we are held to the same restrictions as with a primary claim and cannot balance bill the patient.

That said, I also suggest researching the secondary denial further if you haven't already. Some payers will deny a service as non-covered because it's not a covered benefit in the PATIENT's policy, not because it's an exclusion from the provider contract. I have had to call and directly ask "is this an excluded service in the patient's policy?" before I could get a straight answer. If it's non-covered because the employer made a specific exclusion or the patient didn't purchase that coverage rider, then the balance should be patient responsibility.

Tracy
 
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