Two insurances and both paid as primary

[navila0508]

What does your office do in the case where both insurances a patient carries, pays as primary? Do you refund the second payment? Contact patient to coordinate benefits and wait for a recoup? In this case its a uhc and bcbs

tia

 

[mitchellde]

You refund the patient if they have two primary payers. The patient is paying the premiums for both as primary. It is not unheard of just not common.

 

[thomas7331]

I would not recommend refunding this without first doing some investigation. 99% of the time this is a payer error and once the payer identifies the error they will be recouping it. If you've refunded it to the patient, then you will be in the position of having to inconvenience your patient by billing them for the refund that you made. I'd recommend contacting the payers and working with them to resolve this. In all my years working in billing and claims processing, I only once encountered a payer that said that the patient's plan did not coordinate with other insurance plans.

 

[mitchellde]

If they are both primary then there is no coordination of benefits. You send the claim to both payers as primary. A patient can have as much coverage as they can afford. I work two full time jobs and have primary insurance with both. I pay the premiums for both so if there is an overpayment then I should receive the refund since I paid for that much coverage. It would s not common but you will find that workaholics often do have two primary carriers.

 

[CodingKing]

The odds of a payer not have a COB clause is so small that you just cant assume that both insurances are primary. Yes its possible you can be the policy holder for both plans but if they are both active employee commercial carriers the payer with the earliest effective date will usually be primary. What does happen all the time is payer A and B have no idea the patient has other coverage. I would never assume they know about each other and that both are primary, it just doesn't happen enough to make that assumption.

Here is a good write up on the National Association of Health Insurance Commissioners (NAIC) guidelines that most payers follow.

https://www.excellusbcbs.com/download/files/cob.pdf

 

[KMCFADYEN]

I agree with Coding King.
It is more common that it is an error on the insurance part and the member just needs to COB.

 

[JEYCPC]

Me too, I agree w/CodingKing and KMCFADYEN. Even if both insurance companies paid, I would not refund the patient. One of the insurance companies is bound to return with their hand out.

Is the patient the policy holder for both policies? If the spouse is the policy holder, what happened to the birthday rule? Although my husband is on my policy, his card has him listed as the policy holder.

Oh for a simple life.

 

[danskangel313]

When we have this happen, we contact the patient and request they speak with their insurance carriers to get the COB issue straightened out. Patients tend to be more eager to help if they find out their ins carriers aren't processing their claims correctly. We do not alert the patients of any overpayments nor do we ever refund a patient in these situations. Of course there's always the option to wait for the ins carriers to get things straightened out resulting in a recoup or request for a refund, however we stick to using CMS's 60 day refund window across the board, to keep things simple.

As far as the birthday rule goes, it's correct never to assume that's the case. You never know what external factors exist, for example, a court order requiring a parent to supply health insurance even though the birthday rule for both parents says otherwise.

 

[mitchellde]

You do need to refund the patient. There is a lot of information on the Internet with regard to a patient with two primaries. This is from one site called care cloud.
Sometimes a patient’s secondary insurance carrier is privately purchased insurance. They do not always follow the same guidelines as other insurance carriers. Often, they ignore the amount paid by the primary and make payment as if no other insurance is involved, resulting in overpayment.

If that happens, the overpayment amount belongs to the patient because he or she purchased the other insurance plan. Again, the provider cannot just keep the money and the provider cannot collect more than was billed out for services.

 

[CodingKing]

Me too, I agree w/CodingKing and KMCFADYEN. Even if both insurance companies paid, I would not refund the patient. One on the insurance companies is bound to return with their hand out.

Is the patient the policy holder for both policies? If the spouse is the policy holder, what happened to the birthday rule? Although my husband is on my policy, his card has him listed as the policy holder.

Oh for a simple life.

The birthday rule applies to children covered by both parents (it gets trickier when divorce is involved). The situation with you and your husband follows the Dependent vs non-dependent rule. The plan where your husband is the policy holder is primary to your plan since where he is considered a dependent.

 

[thomas7331]

You do need to refund the patient. There is a lot of information on the Internet with regard to a patient with two primaries. This is from one site called care cloud.
Sometimes a patient’s secondary insurance carrier is privately purchased insurance. They do not always follow the same guidelines as other insurance carriers. Often, they ignore the amount paid by the primary and make payment as if no other insurance is involved, resulting in overpayment.

If that happens, the overpayment amount belongs to the patient because he or she purchased the other insurance plan. Again, the provider cannot just keep the money and the provider cannot collect more than was billed out for services.

Debra, think about what you are saying! Sure, people can purchase as much coverage as they want, but having coverage does not entitle the policyholders to collect amounts above and beyond the liability incurred for the services, unless it's specifically a policy that provides for financial assistance to a patient during an illness. If a covered loss is paid in full, the obligations of the payers are satisfied. If that were not the case, anyone could buy three or four policies and enrich themselves by going to medical appointments. It would be a gross incentive to both patients and providers to abuse the system and drive up the cost of coverage for everyone.

As a provider, I would be extremely cautious about this - you're correct that the provider cannot keep the money, but I would not want to give any hint that I was a part of a scheme to get funds from a payer in excess of payment in full. In the case I mentioned above where a payer insisted that their overpayment belonged to the patient, I advised the provider to refund the payment back to the payer with the instructions that if they really felt it belonged to the policyholder, then that where they should send it, but that my provider should not refund it to the patient themselves since the patient did not make the payment.

 

[danskangel313]

The birthday rule applies to children covered by both parents (it gets trickier when divorce is involved). The situation with you and your husband follows the Dependent vs non-dependent rule. The plan where your husband is the policy holder is primary to your plan since where he is considered a dependent.

Just to piggy-back on this, this is what AAPC says:

"When a child is covered by insurance plans from both parents the “birthday rule” is used to determine the primary and secondary insurance. According to the National Association of Insurance Commissioners, under the birthday rule, the health plan of the parent whose birthday comes first in the calendar year is designated as the primary plan...."

"There are additional guidelines to the birthday rule:

A. If both parents have the same birthday the primary coverage reverts to the oldest policy

B. When regular coverage and COBRA coverage are in play, the regular coverage takes priority

C. In divorce cases where the custodial parent has not remarried—the custodial parent’s plan is primary, and the non-custodial parent’s is secondary. If one parent has a group policy and the other has an individual plan, the group plan becomes the primary insurance.

D. In divorce cases where the custodial parent has remarried—The custodial parent coverage is primary, with the step-parent being secondary. The non-custodial parent is the payer of last resort.

This [the Birthday Rule] is not a law and may not be followed by all payers. State laws regarding coverage policies involving minors and custodial parents may supersede the payers’ rules including the “Birthday rule.”

Tricky indeed!

 

[JEYCPC]

As a provider, I would be extremely cautious about this - you're correct that the provider cannot keep the money, but I would not want to give any hint that I was a part of a scheme to get funds from a payer in excess of payment in full. In the case I mentioned above where a payer insisted that their overpayment belonged to the patient, I advised the provider to refund the payment back to the payer with the instructions that if they really felt it belonged to the policyholder, then that where they should send it, but that my provider should not refund it to the patient themselves since the patient did not make the payment.

Very good point!

Wow, what a chain. I enjoy this type of engagement.

 

[danskangel313]

As a provider, I would be extremely cautious about this - you're correct that the provider cannot keep the money, but I would not want to give any hint that I was a part of a scheme to get funds from a payer in excess of payment in full. In the case I mentioned above where a payer insisted that their overpayment belonged to the patient, I advised the provider to refund the payment back to the payer with the instructions that if they really felt it belonged to the policyholder, then that where they should send it, but that my provider should not refund it to the patient themselves since the patient did not make the payment.

Agreed. Rather than saying you're "playing with fire" by simply sending overpayments to a patient, I'd say it should be you're "flirting with theft, possible embezzlement or larceny" depending on the circumstances.

 

[mitchellde]

I am only reference other sources of information. I ran into this a couple of years back and did extensive research on the issue of a patient having two primaries. There is a ton of information on this and it is is not the same as parent insurance or a spouse have additional coverage. This is one person have coverage from two different carries which they pay for the coverage as a primary payer. It is a special circumstances that you do not find often. I encourage everyone to do the research on this and do not try to apply general rules that you use for patients with primary and secondary coverage. It can be very enlightening.

 

[danskangel313]

It is true that someone can have two plans which they are the primary subscriber for, but there are a substantial amount of laws and regulations and other considerations that apply. I researched it today, referencing only legitimate and reliable sources and only information from 2016 and found this information:

"When you have dual coverage, one of your health insurance plans is the primary plan, while the other is secondary. Coordination of benefits means the primary plan pays claims first, with all or a portion of the remaining costs paid by the secondary plan. Coordination of benefits helps you get the maximum financial benefit from the health insurance coverage. Your secondary plan pays costs that would ordinarily be out-of-pocket costs for you. The coordination also helps the insurance companies avoid overpayment of claims. Even with two health insurance plans, the amount paid for your claims won’t exceed 100 percent of the amount charged by the medical provider. Neither health insurance company will pay for expenses not covered under its plan."

"Double coverage often means you’re paying for redundant coverage.
- You must make your claim with your “primary” plan first. The other plan can pick up the tab for anything not covered, but it won’t pay anything toward the primary plan’s deductible.
- If both plans have deductibles, you’ll have to pay both before coverage kicks in.
- You don’t get to choose which health plan is primary, meaning the one that pays first.
- You don’t get to choose which insurer will pay a certain claim. However, if the first insurer doesn’t cover a certain treatment, or covers it only partially, you can then submit the remainder of the claim to your secondary insurer for payment, assuming the treatment is covered under the second plan."

There is also a incredibly lengthy judicial decision regarding a case in which a person had dual coverage but failed to provide [enough] information to each plan to allow them to COB - lying by omission so to speak. Coincidentally, each policy paid as primary and the provider this guy was seeing kept sending him the overpayments. Apparently he caught on and began frequenting the doc's office on a routine basis for minor procedures here and there. You can assume what happened to him because of this. One of his convictions had to do with the fact that he received money and kept it, knowing it was not owed to him. They racked up the total amount and he was well within a felony level charge.

Yes, dual coverage is legal and possible, but it's not a "two-primary" situation. I have yet to find anywhere that says the patient would be due any overpayments.