WHO SHOULD GET THE REFUND? Both Medicare and Aetna paid as primary

rmarkowitz

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We have a patient in which both Medicare and Aetna paid for multiple dates of service as primary payers. Our office contacted both insurance companies who assured our office that they were in fact the primary payer.

In turn, we contacted the patient to ask that they contact Medicare and Aetna to update their coordination of benefits. The patient has since expired and we even called the patient's spouse to ask them to contact the insurance companies regarding COB as well, with no success.

We are left with the question of who or how we should refund the overpayment(s) received. Any advice or input would be much appreciated.
 

CodingKing

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There is a handy chart starting on page 6 in the following document. Its likely conflicted because CMS either doesn't know whether the commercial coverage is retiree vs or actively employed. Or is spouse is active employed and CMS doesn't realize whether it's a small or large group. I tend to believe the commercial carrier over medicare since they are aware of what type of commercial carrier it is.

https://www.medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf
 

rmarkowitz

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Thanks!

There is a handy chart starting on page 6 in the following document. Its likely conflicted because CMS either doesn't know whether the commercial coverage is retiree vs or actively employed. Or is spouse is active employed and CMS doesn't realize whether it's a small or large group. I tend to believe the commercial carrier over medicare since they are aware of what type of commercial carrier it is.

https://www.medicare.gov/Pubs/pdf/02179-Medicare-Coordination-Benefits-Payer.pdf
Thank you for your help! It is greatly appreciated!
 

scuatro4

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what type of policy does the pt have with Aetna? is it a Medicare Supp? advantage? Hmo? ppo?
 

jensanders16@yahoo.com

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mc/aetna

Definitely figure the type of plan for Aetna... spouse employed? Indemnity? Self pay policy? Since you are aware of the Medicare overpayment, my thought would be to refund Medicare on your area MAC refund form. You have to include the Aetna explanations with your payment as well. They will process the information. If it is not their money, they will send it back and you can try to refund Aetna. Remaining compliant with Medicare should be the bigger priority. But you definitely do not want the money to sit on the account. Medicare's interest is not pretty.
 

rmarkowitz

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what type of policy does the pt have with Aetna? is it a Medicare Supp? advantage? Hmo? ppo?
It is a Aetna Elect Choice Open Access plan, the spouse was employed and from what I can see, using the information that 'CodingKing' was kind enough to share with me, it appears that Medicare should in fact be secondary, which is what we were led to believe but Medicare was not in agreement.

We are in the process of communicating with someone at CMS to see what can be done to refund Medicare. Thank you.
 

rmarkowitz

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Definitely figure the type of plan for Aetna... spouse employed? Indemnity? Self pay policy? Since you are aware of the Medicare overpayment, my thought would be to refund Medicare on your area MAC refund form. You have to include the Aetna explanations with your payment as well. They will process the information. If it is not their money, they will send it back and you can try to refund Aetna. Remaining compliant with Medicare should be the bigger priority. But you definitely do not want the money to sit on the account. Medicare's interest is not pretty.
It is a Aetna Elect Choice Open Access plan, the spouse was employed and from what I can see, using the information that 'CodingKing' was kind enough to share with me, it appears that Medicare should in fact be secondary, which is what we were led to believe but Medicare was not in agreement.

We are in the process of communicating with someone at CMS to see what can be done to refund Medicare. Thank you for your help!
 
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updating insurance information

I know that some of the jurisdictions if you call into your assigned rep with your jurisdiction you can actually sometimes update the information on behalf of the patient if you have verifiable proof (type of policy - who was the primary insured - dates of coverage) and they will update on their end. Aetna would not be the same way but you might be able to back into updating their coverage that way. I know not all jursidictions are created equal that way but you DO have a specific advocate at medicare who can try and navigate this with you and that IS a possibility in some states. Sounds like you may already be on your way to fixing it though, good luck!
 

kkvist

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Kkm

Understanding if the patient was on Hospice at the time of death will help determine which payer should be refunded. If she was on Hospice, then Aetna should be refunded.
 

rmarkowitz

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I know that some of the jurisdictions if you call into your assigned rep with your jurisdiction you can actually sometimes update the information on behalf of the patient if you have verifiable proof (type of policy - who was the primary insured - dates of coverage) and they will update on their end. Aetna would not be the same way but you might be able to back into updating their coverage that way. I know not all jursidictions are created equal that way but you DO have a specific advocate at medicare who can try and navigate this with you and that IS a possibility in some states. Sounds like you may already be on your way to fixing it though, good luck!
Thank you for your input! I actually was about to get in contact with a direct contact at Medicare who has assigned this case to the Critical Inquiry Unit - we hope to have this resolved soon!
 

rmarkowitz

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Understanding if the patient was on Hospice at the time of death will help determine which payer should be refunded. If she was on Hospice, then Aetna should be refunded.
Thank you! The patient was not on hospice at the time of death, which is further evidence we believe Medicare should be refunded. We are now working with a direct contact at Medicare and hope to have it resolved soon! Thank you for your input, this was very helpful!
 
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