Secondary coverage when primary denies with zero patient responsibility

honeybee

Networker
Messages
54
Best answers
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I work in a PT clinic and we have a very persistent patient who is afraid he will not be approved for further auth with his primary ins and wants any denials from primary rolled to his secondary for payment insisting he will be covered.

The patient has AARP Medicare Complete under UHC as prime with no visit limit however auth (ACN) is required through Optum Health. His secondary is Aetna which requires no auth and has a limit of 60 visits per calendar year, so he is well covered under the secondary plan and they do coordinate benefits with the primary carrier.

The issue is if UHC/AARP were to deny further auth the claims submitted will be denied in full with zero patient responsibility and a full provider contractual obligation listed for the balance. My understanding and experience in dealing with similar COB scenarios has always been that the secondary carrier will only consider amounts applied to the patients financial responsibility therefore we would not be paid from his secondary even though he technically may have the benefit available. I have tried to explain this to the patient and he insists that Aetna has said they will pay in this scenario and we can simply call and obtain auth so they will pay.

Could we still treat the patient and have him sign a waiver stating he could be responsible if the secondary carrier does not pay? What is the best way to handle this situation. I already know that we can't obtain auth from Aetna when it is not required to begin with and generally we can't balance bill a patient when the claim denies and the EOB shows no patient responsibility.
 

jtk021996

New
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3
Location
New Orleans
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Hi,
AARP Medicare Complete is a Medicare Advantage Plan. If your provider is a contracted provider with the MA, you can not have the member sign an ABN like document to make the member responsible for payment. I would contact provider relations at the MA and at Aetna for the requirements.

Good Luck!
Pamela
 

honeybee

Networker
Messages
54
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Thank you for your response, I didn't feel a waiver would be appropriate either. I know we cant apply these type of denials to a patients responsibility but he doesn't understand.
 
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