Wiki Second Insurance Allowable more than Primary

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KimBest

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I'm curious what the correct thing to do with a credit balance on account. We have several patients that have 2 commercial insurances and their primary will pay and leave a zero balance and the secondary comes in and pays because the allowable is higher than the primary. What do I do with that money? Refund patient or negative contractual?

Example:

Primary paid $108.59 on a $145 charge and write off was $36.41
Secondary paid $18.84 because their allowable was $127.43.
Creating an $18.84 credit on account.

Thanks for your help!!
 
Interesting that the secondary has the clause that they will make up the difference. You would need to post using the secondary's allowed. The primaries allowed becomes a partial payment.
 
Don't quite understand. If the primary paid the claim in full, why would you bill the secondary?
 
You haven't been overpaid because you did not receive more than the billed amount of $145.00 ($108.59 + $18.84 = $127.43).

I would remove the contractual adjustment on the primary payment, post the secondary payment and then adjust off the remaining $17.57 ($145.00 - $127.43 = $17.57).
 
If you have a contract with the primary insurance, don't you have to accept their approved amount for the claim if it meets your contract's fee schedule?
I still don't think secondary insurance should be billed if the primary insurance EOB was correct and shows no patient responsibility.. What am I missing here?
 
Which allowance rules?

This can be a tricky situation. Which guidelines to follow-primary or secondary? In our large multispecialty practice the rule of thumb is the last payer rules. I generally see this with Cigna secondary, we adjust up to their accepted rate and close the claim. But what happens when the secondary allows less? If $200 is allowed, the first pays $100, but the second will only pay $50 because their contracted rate is $150., or nothing at all if the primary allowed amount exceeds their fee schedule. Our policy is if we are contracted with both insurances we follow the latest payer. Personally I have been balance billed by a hospital because the second payer allowed less than the first, despite both payers being in network, so it seems to me that there is no hard rule regarding this. If anyone knows of one, please share!
 
I am still not getting this. If the primary insurance says the patient has no responsibility, why was a secondary insurance billed? If there is a pt responsibility indicated on the primary payment, ok, then a 2nd insurance should be billed. However if the secondary overpays the balance due on the claim, they might be processing this claim as primary. The 2nd insurance might do an audit in the future, and trust me, if they find out they are in fact secondary, they will request a refund from the provider.
 
Secondary allowed higher than primary

I am having this same situation. A patient has Aetna and Blue Cross. Aetna paid, we did their adjustment and there was a $30 copay billed to BC. BC paid the copay plus the amount of the adjustment as BC's allowable is higher than Aetna's. The patient is stating all her other providers give her a refund of the overpayment made by BLUE CROSS- not her. I feel she is trying to pull a fast one to get money out of us, but I need to know the legality of this. Does anyone have any legal reference that I can use as confirmation to the patient we are billing correctly or that would give me grounds to let our providers know we need to refund this lady? I prefer the former, but if the latter is the correct thing to do, that is best.
I need to call this lady back so if someone can post something in the next day or two, that would be awesome.
Thanks!
 
just4funlead said:
I am having this same situation. A patient has Aetna and Blue Cross. Aetna paid, we did their adjustment and there was a $30 copay billed to BC. BC paid the copay plus the amount of the adjustment as BC's allowable is higher than Aetna's. The patient is stating all her other providers give her a refund of the overpayment made by BLUE CROSS- not her. I feel she is trying to pull a fast one to get money out of us, but I need to know the legality of this. Does anyone have any legal reference that I can use as confirmation to the patient we are billing correctly or that would give me grounds to let our providers know we need to refund this lady? I prefer the former, but if the latter is the correct thing to do, that is best.
I need to call this lady back so if someone can post something in the next day or two, that would be awesome.
Thanks!
Click to expand...

Usually the secondary won't pay more that the full allowed amount of the primary. I'm not sure of any legal references other than your contract w/ the payer. It sounds like the Blue cross doesn't have the lesser of COB language which means they make up the differnce. If any doubt contact Blue Cross for an answer and get the name of the rep and/or a reference number. If patient has a problem with the answer they can take it up with Blue cross.
 
Contact BCBS to be sure. I was contacted by BCBS in the past about a refund due to one of our patients when it was their BCBS policy that overpaid (patient hadn't paid our provider anything)
BCBS confirmed that the type of plan that patient was enrolled with, that any overage/credit would go to the patient.
I can't remember many details other than that, but I would definitely contact the patient's BCBS plan to be sure & not just take the patient's word for it. If BCBS doesn't confirm what the patient is claiming, then let the patient know to take it up with them direct.
 
It sounds like a situation where the secondary thinks they are primary. I would contact both insurances, and if they both think they are primary, then the patient needs to contact both of them to get that straightened out.


John M., BS, CPC-A, CPB
 
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