Wiki REVERSING MEDICARE ADJUSTMENTS

[jamiepeters]

I am trying to find out what the rule is for reversing Medicare adjustments when a secondary insurance has paid more that what Medicare left as the patient's responsibility. I have already tried refunding the secondary insurances' overpayment and they sent it back to us. Can anyone help with what the rules are about reversing Medicare's adjustments?

Thank you

 

[OpenClaims]

The secondary insurance may be paying as primary, or their allowable is more than Medicare's. They see in their system that they paid you correctly so when you send a refund they send it back. I would call the secondary insurance plan and see if they are processing as secondary or primary, and then go from there. What is their allowable for primary/secondary? It could be a coordination of benefits issue, maybe the patient is employed and the commercial technically should be first.

 

[thomas7331]

I agree with the post above, you should continue to work with this payer to get this resolved. To your question about reversing Medicare adjustments, it's not appropriate to do so - the Medicare payment rules carry the force of the law behind them. You can't unilaterally decide that the adjustments are incorrect and reverse them. If Medicare is in fact the primary payer, your provider is only entitled to the payment that Medicare states they are eligible to receive.

I would escalate this issue to a supervisor with the secondary payer if they have paid more than the total patient share that Medicare has indicated. If the secondary payer absolutely refuses to adjust their claim and retract their overpayment and insists that this was paid correctly, then that credit balance would then theoretically belong to the patient, not to the provider, since the payer is making the payment on behalf of the patient and the patient (or their employer) has purchased this plan for that purpose. In that case I would refund the overpayment to the patient as a last resort, not reverse any Medicare adjustments.

 

[jamiepeters]

Thank you both for your response. I also was leaning towards refunding the patient but since another co-worker felt we could reverse Medicare's adjustment I wanted to be sure what I was saying was correct. I have already called the Secondary insurance and confirmed they are paying as the secondary and they say they don't follow Medicare rules/guidelines as they have their own. I also already tried sending a refunding check which they sent back with a letter saying they paid it correctly. I will call and escalate to a supervisor so I have that documented as well prior to refunding the patient. Thanks again for responding.