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Thread: medicare secondary insurance

  1. #1
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    Question medicare secondary insurance

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    If patient has united healthcare and medicare as secondary.
    Patient comes in for PE 99397 v700 which we billed but medicare does not recognized PE codes how would you billed the secondary insurance for this encounter? Any suggestions are appreciated...:0)

  2. #2
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    Quote Originally Posted by perkins05 View Post
    If patient has united healthcare and medicare as secondary.
    Patient comes in for PE 99397 v700 which we billed but medicare does not recognized PE codes how would you billed the secondary insurance for this encounter? Any suggestions are appreciated...:0)
    We bill according to the primary's rules, since typically they cover the majority of the service. For a situation such as this one, though I have a few questions of my own:
    1. If the patient is over 65, why is UHC primary? Medicare should have taken over at this point.
    2. Assuming Medicare should be primary, does this visit not qualify for Medicare's AWV? (See: http://blogs.hcpro.com/medicarefind/...ellness-visit/)

    If you bill this out as 99397 to Medicare, they will deny, and UHC won't pay either. There's no reason that UHC should be primary if the beneficiary is over 65. If they aren't 65 yet, then 99397 isn't the right code anyways, so I'd make my determination based on how the patient's prevenive benefits looked - if they cover most services with no deductible, then I'd go by commercial rules. If the majority of the balance is going to end up at Medicare anyways, you'd be better off with the AWV code, if you can bill it. I hope that helps, and wasn't as confusing as it felt when I typed it.

  3. #3
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    Default I thought something I said sounded funny...

    Correction: If the patient's still working, or their spouse is working, and the UHC policy is for a Large Group Health Plan, UHC could be primary...I apologize if that caused any confusion...(By the way, this is an awesome cheat-sheet, for anyone who's never seen/used it: http://www.cms.gov/MLNProducts/downl...Fact_Sheet.pdf).

    That doesn't really change my answer, though - if UHC is really primary, check the patient's benefits for preventive coverage. If the visit will be covered without applying a deductible (which is usually the case, when it is a covered benefit), then I'd go ahead and bill the 99397 to UHC. I would opt for the Medicare AWV code, if they don't have wellness benefits, or if the benefit is subject to a deductible, to avoid sticking the patient with a large out-of-pocket balance. Hope that made a little more sense!
    Last edited by btadlock1; 07-26-2011 at 06:21 PM.

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