Wiki patient with two insurances

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lec121661

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I need help with a scenario patient has commerical insurance as primary insurance with a copay of say $40.00 and secondary insurance is medicare. patient comes into the office for a consultation to a specialists. commerical insurance does not follow medicare guidelines for not recognizing consultation cpt codes. what would you do in this instance submit the claim to medicare wait for denial and the amount the patient is already responsbile for is the copay. would you bill the patient or write it off to bad debt? any help would be appreciated
 
You can try changing the codes before you submit to the secondary.
But since the nonconforming primary is likely paying higher than the allowable for medicare they will most likely not pay any way.
 
Paytrea@aol.com

Depending on who the insurer is, some commercial insurances (oxford, fidelis) do follow the Medicare guidelines for consultations. I'm not sure if Medicare would give you an issue for submitting a consult code as secondary but you can change the code to an office visit to be safe. I hope that helps. :)
 
If you change the code to submit to Medicare then the claim will deny as the codes do not match the RA. There is no equivalent way to code for the consult. CMS stated to bill to the primary the same way you would bill to Medicare or bill to the primary the consult code and know that Mediciare will deny any payment and you cannot bill the patient since Medicare says a consult service does not exisit.
 
thank you all for your responses. so let me just clarify it the patient has medicare we can not bill the balance for consult, but what if the secondary is commerical insurance can we bill the patient then? and thanks again


LaTanya Cross,CPC, CCS-P
 
Benefit Analyst

lec121661 said:
I need help with a scenario patient has commerical insurance as primary insurance with a copay of say $40.00 and secondary insurance is medicare. patient comes into the office for a consultation to a specialists. commerical insurance does not follow medicare guidelines for not recognizing consultation cpt codes. what would you do in this instance submit the claim to medicare wait for denial and the amount the patient is already responsbile for is the copay. would you bill the patient or write it off to bad debt? any help would be appreciated
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Reply: 11/22/2010- Bill the commercial primary insurance and balance bill Medicare. Unless Medicare stipulates on the EOB that the patient is not responsible (or can't be billed) you can bill the patient. Make sure you have your coordination of benefits correct though, this can make a big difference, but the insurance will let you know if your COB are incorrect.
 
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Q. Will Medicare contractors accept the CPT consultation codes when Medicare is the secondary payer?

A. Medicare will also no longer recognize the CPT consultation codes for purposes of determining Medicare secondary payments (MSP). In MSP cases, providers must bill an appropriate E/M code for the E/M services previously reported and paid using the CPT consultation codes. If the primary payer for the service continues to recognize CPT consultation codes for payment, providers billing for these services may either:

• Bill the primary payer an E/M code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due; or

• Bill the primary payer using a CPT consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due.

Q. Can a provider provide an advance beneficiary notice (ABN) to the beneficiary and then bill his or her charge for the consultation after the consultation is billed and denied by Medicare?

A. No, when a CPT consultation code is reported to Medicare, the claim is not denied. Instead, the claim is returned to the provider for a different CPT code because Medicare recognizes another code for payment of E/M services that may be described by CPT consultation codes. Once the claim is resubmitted to report an appropriate, payable E/M code (other than a CPT consultation code) for a medically reasonable and necessary E/M service, the beneficiary can only be billed any applicable Medicare deductible and coinsurance amounts that apply to the covered E/M service.

http://www.cms.gov/MLNMattersArticles/downloads/SE1010.pdf
 
I work with a practice that has repeatedly tried to bill Medicare seconday for a consultation, each time the code was changed to an appropriate E&M level the claim denied as not matching the RA. Then it was sent on paper and the claim denied as not matching the RA. Then they appealed the denial and the determination was that the primary had already paid an amount that exceeded Medicare allowable for the selected E&M code. They were told if the leave it as a consult code it would deny and the patient is not liable for any balance. They have tried this numerous times with the same response. So if you are changing the code to an E&M then be prepared!
 
We have quite a few patients with Commercial primary, Medicare 2ndary. We've found the best way to bill is to follow Medicare guideline by submitting the claim to the commercial ins with 99201-99205 code then on to Medicare.
If you billed consult code to the commercial, you HAVE TO CHANGE the code for Medicare.
By just billing the "new patient" code from the beginning, you don't have to worry about making sure to change it for Medicare or getting denials from Medicare for using the invalid CPT
You can't collect the copay since the patient has Medicare. Medicare sometimes pays all of commercial copay or pays a portion with a 20% to the patient.
When Medicare stopped recognizing the consult codes, this is one of the "scenarios" for billing that was presented by Medicare as an example.
 
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According to WPS, which is our Medicare Carrier, we have two choices...forget the consult code and go straight to the new patient codes or bill the consult code to the primary and then RECODE it for the Medicare...but keeping in mind that the EOB will not match...that is a little detail they did not know how to handle. We go straight for the new patient codes for ANY medicare and Tricare patient. It saves a lot of headache in the end. Also, when you consider the amount of time and resubmissions you have to do, it really ends up being more cost effective doing it like that.
Rena
 
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