Re: Secondary billing

[Guest guest]

Typically the secondary will pick up the

patient’s responsibility. If the secondary doesn’t cover the primary’s

deductible or copay (I’m guessing Medicare?), then they will pay nothing

and you bill the patient for $27. If Medicare is primary, they should be

automatically forwarding the claim to the secondary. If they don’t,

work with your patient. The patient should go to Medicare and give

Medicare their secondary’s information. But if you do need to file

a claim, I would file it for only the $27. You need to attach the primary

insurance EOB. Even if the patient doesn’t have Medicare, the

primary should be advised that the patient has dual coverage (for example they

have Anthem through the patient’s work and GEHA through the spouse’s

work), and vice-versa. Many times patients tell us that their primary is

the one that has better coverage (often the spouse!), but typically the

insurance co’s will require the patient’s insurance to be primary

and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011

5:53 PM

To:

Subject:

Secondary billing

I should know the answer to this but I don't. Can

anyone tell me if the secondary payer has a lower allowable than the primary,

do I then have to adjust based on the secondary?

Example: I was paid by a private primary $110 with something like $27 as

the patient's responsibility. Then it went to GEHA as secondary which only

allows something like $82. So, do I get to bill the patient for the

remainder from the primary or do I write it off per the secondary?

Carla

[Guest guest]

Typically the secondary will pick up the

patient’s responsibility. If the secondary doesn’t cover the primary’s

deductible or copay (I’m guessing Medicare?), then they will pay nothing

and you bill the patient for $27. If Medicare is primary, they should be

automatically forwarding the claim to the secondary. If they don’t,

work with your patient. The patient should go to Medicare and give

Medicare their secondary’s information. But if you do need to file

a claim, I would file it for only the $27. You need to attach the primary

insurance EOB. Even if the patient doesn’t have Medicare, the

primary should be advised that the patient has dual coverage (for example they

have Anthem through the patient’s work and GEHA through the spouse’s

work), and vice-versa. Many times patients tell us that their primary is

the one that has better coverage (often the spouse!), but typically the

insurance co’s will require the patient’s insurance to be primary

and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011

5:53 PM

To:

Subject:

Secondary billing

I should know the answer to this but I don't. Can

anyone tell me if the secondary payer has a lower allowable than the primary,

do I then have to adjust based on the secondary?

Example: I was paid by a private primary $110 with something like $27 as

the patient's responsibility. Then it went to GEHA as secondary which only

allows something like $82. So, do I get to bill the patient for the

remainder from the primary or do I write it off per the secondary?

Carla

[Guest guest]

Typically the secondary will pick up the

patient’s responsibility. If the secondary doesn’t cover the primary’s

deductible or copay (I’m guessing Medicare?), then they will pay nothing

and you bill the patient for $27. If Medicare is primary, they should be

automatically forwarding the claim to the secondary. If they don’t,

work with your patient. The patient should go to Medicare and give

Medicare their secondary’s information. But if you do need to file

a claim, I would file it for only the $27. You need to attach the primary

insurance EOB. Even if the patient doesn’t have Medicare, the

primary should be advised that the patient has dual coverage (for example they

have Anthem through the patient’s work and GEHA through the spouse’s

work), and vice-versa. Many times patients tell us that their primary is

the one that has better coverage (often the spouse!), but typically the

insurance co’s will require the patient’s insurance to be primary

and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011

5:53 PM

To:

Subject:

Secondary billing

I should know the answer to this but I don't. Can

anyone tell me if the secondary payer has a lower allowable than the primary,

do I then have to adjust based on the secondary?

Example: I was paid by a private primary $110 with something like $27 as

the patient's responsibility. Then it went to GEHA as secondary which only

allows something like $82. So, do I get to bill the patient for the

remainder from the primary or do I write it off per the secondary?

Carla

[Guest guest]

During my billing course, the guy mentioned that when a pt has dual coverage the persons who's birthday comes earlier is assumed to be the primary...but I never came across this situation

 

Typically the secondary will pick up the patient’s responsibility.  If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27.  If Medicare is primary, they should be automatically forwarding the claim to the secondary.  If they don’t, work with your patient.  The patient should go to Medicare and give Medicare their secondary’s information.  But if you do need to file a claim, I would file it for only the $27.  You need to attach the primary insurance EOB.  Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa.  Many times patients tell us that their primary is the one that has better coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

 

Clear as mud?

 

 

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011 5:53 PMTo:

Subject: Secondary billing

 

 

 

I should know the answer to this but I don't.  Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? 

Example:  I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82.  So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?

Carla

-- M.D.www.elainemd.comOffice: Go in the directions of your dreams and live the life you've imagined.

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[Guest guest]

My understanding is you can’t charge more than what the

secondary says the patient is responsible for. Unless you don’t

participate with the secondary insurance and then you can charge up the

amount the primary says the patient is responsible for.

From:

[mailto: ]

On Behalf Of Pratt

Sent: Tuesday, March 01, 2011 10:13 AM

To:

Subject: RE: Secondary billing

Typically

the secondary will pick up the patient’s responsibility. If the

secondary doesn’t cover the primary’s deductible or copay

(I’m guessing Medicare?), then they will pay nothing and you bill the

patient for $27. If Medicare is primary, they should be automatically

forwarding the claim to the secondary. If they don’t, work with your

patient. The patient should go to Medicare and give Medicare their

secondary’s information. But if you do need to file a claim, I

would file it for only the $27. You need to attach the primary insurance

EOB. Even if the patient doesn’t have Medicare, the primary should

be advised that the patient has dual coverage (for example they have Anthem

through the patient’s work and GEHA through the spouse’s work), and

vice-versa. Many times patients tell us that their primary is the one that

has better coverage (often the spouse!), but typically the insurance co’s

will require the patient’s insurance to be primary and the spouse’s

to be secondary.

Clear as

mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From:

[mailto: ] On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011 5:53 PM

To:

Subject: Secondary billing

I should know the

answer to this but I don't. Can anyone tell me if the secondary payer has

a lower allowable than the primary, do I then have to adjust based on the

secondary?

Example: I was paid by a private primary $110 with something like $27 as

the patient's responsibility. Then it went to GEHA as secondary which only

allows something like $82. So, do I get to bill the patient for the

remainder from the primary or do I write it off per the secondary?

Carla

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[Guest guest]

Kathy,Thank you. This is how I've handled it in the past but it seems wrong somehow. An even worse example would be if the patient has not met their deductible at all with the well paying primary which would have paid $110.... then the secondary only allows $82 and that is all we could collect. Now, in thinking about this it brings up another question. Why is it that I cannot reduce the patient's primary plan's responsibility (which would be fraud) but another insurance company can?CarlaTo: Sent: Tue, March 1, 2011 8:50:47 AMSubject: RE: Secondary billing

My understanding is you can’t charge more than what the

secondary says the patient is responsible for. Unless you don’t

participate with the secondary insurance and then you can charge up the

amount the primary says the patient is responsible for.

From:

[mailto: ]

On Behalf Of Pratt

Sent: Tuesday, March 01, 2011 10:13 AM

To:

Subject: RE: Secondary billing

Typically

the secondary will pick up the patient’s responsibility. If the

secondary doesn’t cover the primary’s deductible or copay

(I’m guessing Medicare?), then they will pay nothing and you bill the

patient for $27. If Medicare is primary, they should be automatically

forwarding the claim to the secondary. If they don’t, work with your

patient. The patient should go to Medicare and give Medicare their

secondary’s information. But if you do need to file a claim, I

would file it for only the $27. You need to attach the primary insurance

EOB. Even if the patient doesn’t have Medicare, the primary should

be advised that the patient has dual coverage (for example they have Anthem

through the patient’s work and GEHA through the spouse’s work), and

vice-versa. Many times patients tell us that their primary is the one that

has better coverage (often the spouse!), but typically the insurance co’s

will require the patient’s insurance to be primary and the spouse’s

to be secondary. Clear as

mud?

Pratt Office Manager Oak Tree Internal Medicine P.C www.prattmd.info

From:

[mailto: ] On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011 5:53 PM

To:

Subject: Secondary billing

I should know the

answer to this but I don't. Can anyone tell me if the secondary payer has

a lower allowable than the primary, do I then have to adjust based on the

secondary?

Example: I was paid by a private primary $110 with something like $27 as

the patient's responsibility. Then it went to GEHA as secondary which only

allows something like $82. So, do I get to bill the patient for the

remainder from the primary or do I write it off per the secondary?

Carla

CyberDefender has scanned this email for potential threats.

Version 2.0 / Build 4.03.29.01

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[Guest guest]

Wait a second. I'm only half monitoring this thread so forgive if I'm off base here... BUT, some 2nd has deductables and the like as well. Just because someone is NOT paying at all or in full does NOT mean that you are not entitled to the full amount "Allowed by Medicare".... As a matter of fact, not collecting up to that MAX in any and all cases could be construded as Fraud the times that you accept less here and more somewhere else. If Medicare pays you that $110 or "Allows" it with an 80-20 split so you need to turn to 2nd or patient and get that last 20% from one of them, then if you don't go after it, then you are "accepting" less in those cases... The 2nd may only pay $82 dollars but if the Medicare "Allowable" is $110 and in most cases you would go after and collect that entire $110 between the

any and all parties involved, then you must do that consistantly across the board. The 2nd is NOT allowed to suddenly re-write the Medicare Fee Schedule and Medicare Law.

Now perhaps there is something in this 2nd plan that allows for less than full payment of the claims, like perhaps they are now taking on the role of the primary, 1st carriers. But if allowable is $110 and the one and only carrier that paid in the end paid only $82 bucks (which is not 80% of 110, 88 is 80% of 110, BTW.... so they are not attempting to claim that.... so what every their thinking reason or calculations perhaps intentionally shorting you to see if you notice and if not 100,000 times $6 is a lot of profit now isn't it???) then you are just about obligated by law and contract to attempt to go and collect the leftovers from anyone else in the line of payment, and at this point, that is the "Patient Responsibility" in this case.... so obviously 110 minus 82 equals 28 and you should by law and contract attempting to collect $28 bucks from the patient.

I have never heard of a secondary carrier being allowed to flipantly change the Medicare Fee Schedule just to suit their own needs... The Medicare Deductable is what it is, and some plans pay from dollar one and others have their own deductable and other if and whens for when they kick in as well. But in the end the crap roles down hill and someone, usually the patient gets stuck holding the bag and having to pay whatever is leftover after everyone else has paid according to the proper calculations their fair and agreed upon share based on contract and law, 100% of the Medicare Fee Schedule. Heck I have even had a couple of patients with 3rd carriers who then pick up another percentage of the leftovers like a few teenagers we have whose parents are divorced and they are on both parents' plans.... so this one pays first, then percentages of the 2nd and the 3rd, with only 0.24 cents left to attempt to collect from the

parents after the 3rd kicked in... It can get pretty darn silly sometime and not even worth the cost of the stamp and envelope but we are supposed to by law make a good faith attempt to go after this pimple of a balance or we are officially breaking the law. Insane for sure...

It is one of the main reasons many of us still attempt to cooperate and accept this form of insurance... The rules are pretty clear, we all know the rules of the game, nobody is really allowed to play them or change them, they are set in stone, so we all know what to expect and who is responsible for what, and our Seniors and Disabled really apperciate and need us to play along for the most part except perhaps for the upper middle class and the truly well to do.... No carrier is allowed to change or re-write the Medicare Fee Schedule just as we are not allowed to as well.... The rules are pretty clear and rigid and set in stone.... and it is one of the places where the coding and bundling actually adheres to proper coding guidelines so again we all know what to expect, how to properly billing any particular case, and not have to worry about getting hung up on some carrier's lousy bundling policies... So you can bill an

E & M office visit or CPE like code combined with the women's wellcare codes of G0101 & Q0091 for the Breast and Pelvic Exam and the proper collection of the PAP and its chain of custody and get paid and collect for all three... It is one of the better part of Medicare... And another part of reform that was completely ignored by all the Morons who faught over it and claimed to have either patients or doctors as their concern when if fact none of them really did...

That's my two cents for what it is worth....

To: Sent: Tue, March 1, 2011 11:10:14 AMSubject: Re: Secondary billing

Kathy,Thank you. This is how I've handled it in the past but it seems wrong somehow. An even worse example would be if the patient has not met their deductible at all with the well paying primary which would have paid $110.... then the secondary only allows $82 and that is all we could collect. Now, in thinking about this it brings up another question. Why is it that I cannot reduce the patient's primary plan's responsibility (which would be fraud) but another insurance company can?Carla

To: Sent: Tue, March 1, 2011 8:50:47 AMSubject: RE: Secondary billing

My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better

coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?Carla

CyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

[Guest guest]

I have not seen any Medicare supplemental

plans reduce the allowed amount. But we have patients with dual coverage

that are NOT Medicare beneficiaries, and that is when it gets sticky. For

example, I have a patient with Anthem primary and Blue Shield secondary.

The Anthem allowable is less than the Blue Shield allowable. So the

patient responsibility from Anthem was $3.XX and it automatically forwarded to

Blue Shield, which processed the claim incorrectly and didn’t apply the

primary allowable and simply pay the $3.xx. Blue Shield now says the

patient is responsible for $7 and that it applies to his deductible. That

is what I billed the patient, who called to tell me that I was not allowed to

bill him for more than what his primary said. Normally, I wouldn’t

gripe about this, but I spent more than $3 of my time even looking into

it. The fact that the patient is griping about paying an extra $3 and

change really pisses me off. So I appealed the BSCA decision so that they

would not apply more than the $3.xx towards his deductible. It’s a

matter of principal at this point. The patient is difficult to begin with

and this is not really worth my time. But this type of crap from patients

really drives me crazy. Makes me want to adopt a policy that we won’t

bill secondaries, but our contracts won’t allow that, unfortunately.

As soon as we are consistently having a

full schedule (we are close – we averaged 8 unbooked appointments in

February per week and I want it down to 4-5), we will go non-par with

Anthem. I can’t wait. They are a total PITA and my worst

payer.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Bleiweiss

Sent: Tuesday, March 01, 2011

10:32 AM

To:

Subject: Re:

Secondary billing

Wait a second. I'm only half monitoring this thread so

forgive if I'm off base here... BUT, some 2nd has deductables and the like as

well. Just because someone is NOT paying at all or in full does NOT mean that

you are not entitled to the full amount " Allowed by Medicare " .... As

a matter of fact, not collecting up to that MAX in any and all cases could be

construded as Fraud the times that you accept less here and more somewhere else.

If Medicare pays you that $110 or " Allows " it with an 80-20 split so

you need to turn to 2nd or patient and get that last 20% from one of them, then

if you don't go after it, then you are " accepting " less in those

cases... The 2nd may only pay $82 dollars but if the Medicare

" Allowable " is $110 and in most cases you would go after and collect

that entire $110 between the any and all parties involved, then you must do

that consistantly across the board. The 2nd is NOT allowed to suddenly re-write

the Medicare Fee Schedule and Medicare Law.

Now perhaps there is something in this

2nd plan that allows for less than full payment of the claims, like perhaps

they are now taking on the role of the primary, 1st carriers. But if allowable

is $110 and the one and only carrier that paid in the end paid only $82 bucks

(which is not 80% of 110, 88 is 80% of 110, BTW.... so they are not attempting

to claim that.... so what every their thinking reason or calculations perhaps

intentionally shorting you to see if you notice and if not 100,000 times $6 is

a lot of profit now isn't it???) then you are just about obligated by law and

contract to attempt to go and collect the leftovers from anyone else in the

line of payment, and at this point, that is the " Patient Responsibility "

in this case.... so obviously 110 minus 82 equals 28 and you should by law and

contract attempting to collect $28 bucks from the patient.

I have never heard of a secondary carrier

being allowed to flipantly change the Medicare Fee Schedule just to suit their

own needs... The Medicare Deductable is what it is, and some plans pay

from dollar one and others have their own deductable and other if and whens for

when they kick in as well. But in the end the crap roles down hill and someone,

usually the patient gets stuck holding the bag and having to pay whatever is

leftover after everyone else has paid according to the proper calculations

their fair and agreed upon share based on contract and law, 100% of the

Medicare Fee Schedule. Heck I have even had a couple of patients with 3rd

carriers who then pick up another percentage of the leftovers like a

few teenagers we have whose parents are divorced and they are on both parents'

plans.... so this one pays first, then percentages of the 2nd and the 3rd, with

only 0.24 cents left to attempt to collect from the parents after the 3rd

kicked in... It can get pretty darn silly sometime and not even worth the cost

of the stamp and envelope but we are supposed to by law make a good faith

attempt to go after this pimple of a balance or we are officially breaking the

law. Insane for sure...

It is one of the main reasons many

of us still attempt to cooperate and accept this form of insurance... The rules

are pretty clear, we all know the rules of the game, nobody is really allowed

to play them or change them, they are set in stone, so we all know what to

expect and who is responsible for what, and our Seniors and Disabled really

apperciate and need us to play along for the most part except perhaps for the

upper middle class and the truly well to do.... No carrier is allowed to change

or re-write the Medicare Fee Schedule just as we are not allowed to as well....

The rules are pretty clear and rigid and set in stone.... and it is one of the

places where the coding and bundling actually adheres to proper coding

guidelines so again we all know what to expect, how to properly billing any

particular case, and not have to worry about getting hung up on some carrier's

lousy bundling policies... So you can bill an E & M office visit or CPE like

code combined with the women's wellcare codes of G0101 & Q0091 for the

Breast and Pelvic Exam and the proper collection of the PAP and its chain of

custody and get paid and collect for all three... It is one of the better part

of Medicare... And another part of reform that was completely ignored by all

the Morons who faught over it and claimed to have either patients or doctors as

their concern when if fact none of them really did...

That's my two cents for what it is

worth....

From: Carla Gibson

To:

Sent: Tue, March 1, 2011 11:10:14

AM

Subject: Re:

Secondary billing

Kathy,

Thank you. This is how I've handled it in the past but it seems wrong

somehow. An even worse example would be if the patient has not met their

deductible at all with the well paying primary which would have paid $110....

then the secondary only allows $82 and that is all we could collect.

Now, in thinking about this it brings up another question. Why is it that I

cannot reduce the patient's primary plan's responsibility (which would be

fraud) but another insurance company can?

Carla

From: " Kathy

Saradarian, MD "

To:

Sent: Tue, March 1, 2011 8:50:47

AM

Subject: RE:

Secondary billing

My understanding is you can’t charge more than what the

secondary says the patient is responsible for. Unless you don’t

participate with the secondary insurance and then you can charge up the

amount the primary says the patient is responsible for.

From:

[mailto: ]

On Behalf Of Pratt

Sent: Tuesday, March 01, 2011

10:13 AM

To:

Subject: RE:

Secondary billing

Typically the secondary will pick up the patient’s

responsibility. If the secondary doesn’t cover the primary’s

deductible or copay (I’m guessing Medicare?), then they will pay nothing

and you bill the patient for $27. If Medicare is primary, they should be

automatically forwarding the claim to the secondary. If they don’t,

work with your patient. The patient should go to Medicare and give

Medicare their secondary’s information. But if you do need to file

a claim, I would file it for only the $27. You need to attach the primary

insurance EOB. Even if the patient doesn’t have Medicare, the

primary should be advised that the patient has dual coverage (for example they

have Anthem through the patient’s work and GEHA through the

spouse’s work), and vice-versa. Many times patients tell us that

their primary is the one that has better coverage (often the spouse!), but

typically the insurance co’s will require the patient’s insurance

to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From:

[mailto: ]

On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011

5:53 PM

To:

Subject:

Secondary billing

I should know the

answer to this but I don't. Can anyone tell me if the secondary payer has

a lower allowable than the primary, do I then have to adjust based on the

secondary?

Example: I was paid by a private primary $110 with something like $27 as

the patient's responsibility. Then it went to GEHA as secondary which only

allows something like $82. So, do I get to bill the patient for the

remainder from the primary or do I write it off per the secondary?

Carla

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Version 2.0 / Build 4.03.29.01

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[Guest guest]

,In Virginia, if a patient has Medicaid as a secondary, they routinely write off the rest of the allowable. So Medicare will pay the 80% (after the deductable) and Medicaid (claiming that the Medicare 80% is already more than they would pay) writes off the 20% and states clearly that the patient is not responsible for this. So in Virginia, accepting patients with Medicaid as a secondary automatically means you will be paid 20% less than the Medicare allowable. From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 2:02 PMTo: Subject: RE: Secondary billing I have not seen any Medicare supplemental plans reduce the allowed amount. But we have patients with dual coverage that are NOT Medicare beneficiaries, and that is when it gets sticky. For example, I have a patient with Anthem primary and Blue Shield secondary. The Anthem allowable is less than the Blue Shield allowable. So the patient responsibility from Anthem was $3.XX and it automatically forwarded to Blue Shield, which processed the claim incorrectly and didn’t apply the primary allowable and simply pay the $3.xx. Blue Shield now says the patient is responsible for $7 and that it applies to his deductible. That is what I billed the patient, who called to tell me that I was not allowed to bill him for more than what his primary said. Normally, I wouldn’t gripe about this, but I spent more than $3 of my time even looking into it. The fact that the patient is griping about paying an extra $3 and change really pisses me off. So I appealed the BSCA decision so that they would not apply more than the $3.xx towards his deductible. It’s a matter of principal at this point. The patient is difficult to begin with and this is not really worth my time. But this type of crap from patients really drives me crazy. Makes me want to adopt a policy that we won’t bill secondaries, but our contracts won’t allow that, unfortunately. As soon as we are consistently having a full schedule (we are close – we averaged 8 unbooked appointments in February per week and I want it down to 4-5), we will go non-par with Anthem. I can’t wait. They are a total PITA and my worst payer. PrattOffice ManagerOak Tree Internal Medicine P.Cwww.prattmd.info From: [mailto: ] On Behalf Of BleiweissSent: Tuesday, March 01, 2011 10:32 AMTo: Subject: Re: Secondary billing Wait a second. I'm only half monitoring this thread so forgive if I'm off base here... BUT, some 2nd has deductables and the like as well. Just because someone is NOT paying at all or in full does NOT mean that you are not entitled to the full amount " Allowed by Medicare " .... As a matter of fact, not collecting up to that MAX in any and all cases could be construded as Fraud the times that you accept less here and more somewhere else. If Medicare pays you that $110 or " Allows " it with an 80-20 split so you need to turn to 2nd or patient and get that last 20% from one of them, then if you don't go after it, then you are " accepting " less in those cases... The 2nd may only pay $82 dollars but if the Medicare " Allowable " is $110 and in most cases you would go after and collect that entire $110 between the any and all parties involved, then you must do that consistantly across the board. The 2nd is NOT allowed to suddenly re-write the Medicare Fee Schedule and Medicare Law. Now perhaps there is something in this 2nd plan that allows for less than full payment of the claims, like perhaps they are now taking on the role of the primary, 1st carriers. But if allowable is $110 and the one and only carrier that paid in the end paid only $82 bucks (which is not 80% of 110, 88 is 80% of 110, BTW.... so they are not attempting to claim that.... so what every their thinking reason or calculations perhaps intentionally shorting you to see if you notice and if not 100,000 times $6 is a lot of profit now isn't it???) then you are just about obligated by law and contract to attempt to go and collect the leftovers from anyone else in the line of payment, and at this point, that is the " Patient Responsibility " in this case.... so obviously 110 minus 82 equals 28 and you should by law and contract attempting to collect $28 bucks from the patient. I have never heard of a secondary carrier being allowed to flipantly change the Medicare Fee Schedule just to suit their own needs... The Medicare Deductable is what it is, and some plans pay from dollar one and others have their own deductable and other if and whens for when they kick in as well. But in the end the crap roles down hill and someone, usually the patient gets stuck holding the bag and having to pay whatever is leftover after everyone else has paid according to the proper calculations their fair and agreed upon share based on contract and law, 100% of the Medicare Fee Schedule. Heck I have even had a couple of patients with 3rd carriers who then pick up another percentage of the leftovers like a few teenagers we have whose parents are divorced and they are on both parents' plans.... so this one pays first, then percentages of the 2nd and the 3rd, with only 0.24 cents left to attempt to collect from the parents after the 3rd kicked in... It can get pretty darn silly sometime and not even worth the cost of the stamp and envelope but we are supposed to by law make a good faith attempt to go after this pimple of a balance or we are officially breaking the law. Insane for sure... It is one of the main reasons many of us still attempt to cooperate and accept this form of insurance... The rules are pretty clear, we all know the rules of the game, nobody is really allowed to play them or change them, they are set in stone, so we all know what to expect and who is responsible for what, and our Seniors and Disabled really apperciate and need us to play along for the most part except perhaps for the upper middle class and the truly well to do.... No carrier is allowed to change or re-write the Medicare Fee Schedule just as we are not allowed to as well.... The rules are pretty clear and rigid and set in stone.... and it is one of the places where the coding and bundling actually adheres to proper coding guidelines so again we all know what to expect, how to properly billing any particular case, and not have to worry about getting hung up on some carrier's lousy bundling policies... So you can bill an E & M office visit or CPE like code combined with the women's wellcare codes of G0101 & Q0091 for the Breast and Pelvic Exam and the proper collection of the PAP and its chain of custody and get paid and collect for all three... It is one of the better part of Medicare... And another part of reform that was completely ignored by all the Morons who faught over it and claimed to have either patients or doctors as their concern when if fact none of them really did... That's my two cents for what it is worth.... To: Sent: Tue, March 1, 2011 11:10:14 AMSubject: Re: Secondary billing Kathy,Thank you. This is how I've handled it in the past but it seems wrong somehow. An even worse example would be if the patient has not met their deductible at all with the well paying primary which would have paid $110.... then the secondary only allows $82 and that is all we could collect. Now, in thinking about this it brings up another question. Why is it that I cannot reduce the patient's primary plan's responsibility (which would be fraud) but another insurance company can?Carla To: Sent: Tue, March 1, 2011 8:50:47 AMSubject: RE: Secondary billing My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for. From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary. Clear as mud? PrattOffice ManagerOak Tree Internal Medicine P.Cwww.prattmd.info From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?CarlaCyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

[Guest guest]

,

This is true in CA, too. Which is

why we don’t accept Medi-Cal. I was speaking of the commercial

secondaries.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Dr. Brady

Sent: Tuesday, March 01, 2011

12:11 PM

To:

Subject: RE:

Secondary billing

,

In Virginia,

if a patient has Medicaid as a secondary, they routinely write off the rest of

the allowable. So Medicare will pay the 80% (after the deductable) and Medicaid

(claiming that the Medicare 80% is already more than they would pay) writes off

the 20% and states clearly that the patient is not responsible for this. So in Virginia, accepting

patients with Medicaid as a secondary automatically means you will be paid 20%

less than the Medicare allowable.

From:

[mailto: ]

On Behalf Of Pratt

Sent: Tuesday, March 01, 2011 2:02

PM

To:

Subject: RE:

Secondary billing

I have not seen any Medicare supplemental plans reduce the allowed

amount. But we have patients with dual coverage that are NOT Medicare

beneficiaries, and that is when it gets sticky. For example, I have a

patient with Anthem primary and Blue Shield secondary. The Anthem

allowable is less than the Blue Shield allowable. So the patient

responsibility from Anthem was $3.XX and it automatically forwarded to Blue

Shield, which processed the claim incorrectly and didn’t apply the

primary allowable and simply pay the $3.xx. Blue Shield now says the

patient is responsible for $7 and that it applies to his deductible. That

is what I billed the patient, who called to tell me that I was not allowed to

bill him for more than what his primary said. Normally, I wouldn’t

gripe about this, but I spent more than $3 of my time even looking into

it. The fact that the patient is griping about paying an extra $3 and

change really pisses me off. So I appealed the BSCA decision so that they

would not apply more than the $3.xx towards his deductible. It’s a

matter of principal at this point. The patient is difficult to begin with

and this is not really worth my time. But this type of crap from patients

really drives me crazy. Makes me want to adopt a policy that we

won’t bill secondaries, but our contracts won’t allow that,

unfortunately.

As soon as we are consistently having a full schedule (we are close

– we averaged 8 unbooked appointments in February per week and I want it

down to 4-5), we will go non-par with Anthem. I can’t wait.

They are a total PITA and my worst payer.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From:

[mailto: ]

On Behalf Of Bleiweiss

Sent: Tuesday, March 01, 2011

10:32 AM

To:

Subject: Re:

Secondary billing

Wait a second. I'm

only half monitoring this thread so forgive if I'm off base here... BUT, some

2nd has deductables and the like as well. Just because someone is NOT paying at

all or in full does NOT mean that you are not entitled to the full amount " Allowed

by Medicare " .... As a matter of fact, not collecting up to that MAX in any

and all cases could be construded as Fraud the times that you accept less here

and more somewhere else. If Medicare pays you that $110 or " Allows "

it with an 80-20 split so you need to turn to 2nd or patient and get that last

20% from one of them, then if you don't go after it, then you are

" accepting " less in those cases... The 2nd may only pay $82 dollars

but if the Medicare " Allowable " is $110 and in most cases you would

go after and collect that entire $110 between the any and all parties involved,

then you must do that consistantly across the board. The 2nd is NOT allowed to

suddenly re-write the Medicare Fee Schedule and Medicare Law.

Now perhaps there is something in this 2nd plan that allows for less than full

payment of the claims, like perhaps they are now taking on the role of the

primary, 1st carriers. But if allowable is $110 and the one and only carrier

that paid in the end paid only $82 bucks (which is not 80% of 110, 88 is 80% of

110, BTW.... so they are not attempting to claim that.... so what every their

thinking reason or calculations perhaps intentionally shorting you to see if

you notice and if not 100,000 times $6 is a lot of profit now isn't it???) then

you are just about obligated by law and contract to attempt to go and collect

the leftovers from anyone else in the line of payment, and at this point, that

is the " Patient Responsibility " in this case.... so obviously 110

minus 82 equals 28 and you should by law and contract attempting to collect $28

bucks from the patient.

I have never heard of a secondary carrier being allowed to flipantly change the

Medicare Fee Schedule just to suit their own needs... The Medicare Deductable

is what it is, and some plans pay from dollar one and others have their

own deductable and other if and whens for when they kick in as well. But in the

end the crap roles down hill and someone, usually the patient gets stuck

holding the bag and having to pay whatever is leftover after everyone else has

paid according to the proper calculations their fair and agreed upon share

based on contract and law, 100% of the Medicare Fee Schedule. Heck I have even

had a couple of patients with 3rd carriers who then pick up another percentage

of the leftovers like a few teenagers we have whose parents are divorced

and they are on both parents' plans.... so this one pays first, then

percentages of the 2nd and the 3rd, with only 0.24 cents left to attempt to

collect from the parents after the 3rd kicked in... It can get pretty darn

silly sometime and not even worth the cost of the stamp and envelope but we are

supposed to by law make a good faith attempt to go after this pimple of a

balance or we are officially breaking the law. Insane for sure...

It is one of the main reasons many of us still attempt to cooperate and

accept this form of insurance... The rules are pretty clear, we all know the

rules of the game, nobody is really allowed to play them or change them, they

are set in stone, so we all know what to expect and who is responsible for

what, and our Seniors and Disabled really apperciate and need us to play along

for the most part except perhaps for the upper middle class and the truly well

to do.... No carrier is allowed to change or re-write the Medicare Fee Schedule

just as we are not allowed to as well.... The rules are pretty clear and rigid

and set in stone.... and it is one of the places where the coding and bundling

actually adheres to proper coding guidelines so again we all know what to

expect, how to properly billing any particular case, and not have to worry

about getting hung up on some carrier's lousy bundling policies... So you can

bill an E & M office visit or CPE like code combined with the women's

wellcare codes of G0101 & Q0091 for the Breast and Pelvic Exam and the

proper collection of the PAP and its chain of custody and get paid and collect

for all three... It is one of the better part of Medicare... And another part

of reform that was completely ignored by all the Morons who faught over it and

claimed to have either patients or doctors as their concern when if fact none

of them really did...

That's my two cents for what it is worth....

To:

Sent: Tue, March 1, 2011 11:10:14

AM

Subject: Re:

Secondary billing

Kathy,

Thank you. This is how I've handled it in the past but it seems wrong

somehow. An even worse example would be if the patient has not met their

deductible at all with the well paying primary which would have paid $110....

then the secondary only allows $82 and that is all we could collect.

Now, in thinking about this it brings up another question. Why is it that I cannot

reduce the patient's primary plan's responsibility (which would be fraud) but

another insurance company can?

Carla

From: " Kathy Saradarian, MD "

To:

Sent: Tue, March 1, 2011 8:50:47

AM

Subject: RE:

Secondary billing

My understanding is you can’t charge more than what the

secondary says the patient is responsible for. Unless you don’t

participate with the secondary insurance and then you can charge up the amount

the primary says the patient is responsible for.

From:

[mailto: ]

On Behalf Of Pratt

Sent: Tuesday, March 01, 2011

10:13 AM

To:

Subject: RE:

Secondary billing

Typically the secondary will pick up the patient’s

responsibility. If the secondary doesn’t cover the primary’s

deductible or copay (I’m guessing Medicare?), then they will pay nothing

and you bill the patient for $27. If Medicare is primary, they should be

automatically forwarding the claim to the secondary. If they don’t,

work with your patient. The patient should go to Medicare and give

Medicare their secondary’s information. But if you do need to file

a claim, I would file it for only the $27. You need to attach the primary

insurance EOB. Even if the patient doesn’t have Medicare, the

primary should be advised that the patient has dual coverage (for example they

have Anthem through the patient’s work and GEHA through the

spouse’s work), and vice-versa. Many times patients tell us that

their primary is the one that has better coverage (often the spouse!), but

typically the insurance co’s will require the patient’s insurance

to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From:

[mailto: ]

On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011

5:53 PM

To:

Subject:

Secondary billing

I should know the

answer to this but I don't. Can anyone tell me if the secondary payer has

a lower allowable than the primary, do I then have to adjust based on the

secondary?

Example: I was paid by a private primary $110 with something like $27 as

the patient's responsibility. Then it went to GEHA as secondary which only

allows something like $82. So, do I get to bill the patient for the

remainder from the primary or do I write it off per the secondary?

Carla

CyberDefender has scanned this email for potential threats.

Version 2.0 / Build 4.03.29.01

Get free PC security at http://www.cyberdefender.com

[Guest guest]

Same in Illinois.

Tough part is deductible is $130 medicaid pays peanuts so first $130 is free then paid at 80%. Average charges $250/pt per year so.

80% of $120 is $96/250 is 38% of first $250 worth of services. Based on time $48/hour. Loss = $90/hour treating medicaid patients for the first 2 hours a year.

To: Sent: Tue, March 1, 2011 2:11:13 PMSubject: RE: Secondary billing

,

In Virginia, if a patient has Medicaid as a secondary, they routinely write off the rest of the allowable. So Medicare will pay the 80% (after the deductable) and Medicaid (claiming that the Medicare 80% is already more than they would pay) writes off the 20% and states clearly that the patient is not responsible for this. So in Virginia, accepting patients with Medicaid as a secondary automatically means you will be paid 20% less than the Medicare allowable.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 2:02 PMTo: Subject: RE: Secondary billing

I have not seen any Medicare supplemental plans reduce the allowed amount. But we have patients with dual coverage that are NOT Medicare beneficiaries, and that is when it gets sticky. For example, I have a patient with Anthem primary and Blue Shield secondary. The Anthem allowable is less than the Blue Shield allowable. So the patient responsibility from Anthem was $3.XX and it automatically forwarded to Blue Shield, which processed the claim incorrectly and didn’t apply the primary allowable and simply pay the $3.xx. Blue Shield now says the patient is responsible for $7 and that it applies to his deductible. That is what I billed the patient, who called to tell me that I was not allowed to bill him for more than what his primary said. Normally, I wouldn’t gripe about this, but I spent more than $3 of my time even looking into it. The fact

that the patient is griping about paying an extra $3 and change really pisses me off. So I appealed the BSCA decision so that they would not apply more than the $3.xx towards his deductible. It’s a matter of principal at this point. The patient is difficult to begin with and this is not really worth my time. But this type of crap from patients really drives me crazy. Makes me want to adopt a policy that we won’t bill secondaries, but our contracts won’t allow that, unfortunately.

As soon as we are consistently having a full schedule (we are close – we averaged 8 unbooked appointments in February per week and I want it down to 4-5), we will go non-par with Anthem. I can’t wait. They are a total PITA and my worst payer.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of BleiweissSent: Tuesday, March 01, 2011 10:32 AMTo: Subject: Re: Secondary billing

Wait a second. I'm only half monitoring this thread so forgive if I'm off base here... BUT, some 2nd has deductables and the like as well. Just because someone is NOT paying at all or in full does NOT mean that you are not entitled to the full amount "Allowed by Medicare".... As a matter of fact, not collecting up to that MAX in any and all cases could be construded as Fraud the times that you accept less here and more somewhere else. If Medicare pays you that $110 or "Allows" it with an 80-20 split so you need to turn to 2nd or patient and get that last 20% from one of them, then if you don't go after it, then you are "accepting" less in those cases... The 2nd may only pay $82 dollars but if the Medicare "Allowable" is $110 and in most cases you would go after and collect that entire $110 between the any and all parties involved, then you must do that consistantly across the board. The 2nd is NOT allowed to suddenly re-write the

Medicare Fee Schedule and Medicare Law.

Now perhaps there is something in this 2nd plan that allows for less than full payment of the claims, like perhaps they are now taking on the role of the primary, 1st carriers. But if allowable is $110 and the one and only carrier that paid in the end paid only $82 bucks (which is not 80% of 110, 88 is 80% of 110, BTW.... so they are not attempting to claim that.... so what every their thinking reason or calculations perhaps intentionally shorting you to see if you notice and if not 100,000 times $6 is a lot of profit now isn't it???) then you are just about obligated by law and contract to attempt to go and collect the leftovers from anyone else in the line of payment, and at this point, that is the "Patient Responsibility" in this case.... so obviously 110 minus 82 equals 28 and you should by law and contract attempting to collect $28 bucks from the patient.

I have never heard of a secondary carrier being allowed to flipantly change the Medicare Fee Schedule just to suit their own needs... The Medicare Deductable is what it is, and some plans pay from dollar one and others have their own deductable and other if and whens for when they kick in as well. But in the end the crap roles down hill and someone, usually the patient gets stuck holding the bag and having to pay whatever is leftover after everyone else has paid according to the proper calculations their fair and agreed upon share based on contract and law, 100% of the Medicare Fee Schedule. Heck I have even had a couple of patients with 3rd carriers who then pick up another percentage of the leftovers like a few teenagers we have whose parents are divorced and they are on both parents' plans.... so this one pays first, then percentages of the 2nd and the 3rd, with only 0.24 cents left to attempt

to collect from the parents after the 3rd kicked in... It can get pretty darn silly sometime and not even worth the cost of the stamp and envelope but we are supposed to by law make a good faith attempt to go after this pimple of a balance or we are officially breaking the law. Insane for sure...

It is one of the main reasons many of us still attempt to cooperate and accept this form of insurance... The rules are pretty clear, we all know the rules of the game, nobody is really allowed to play them or change them, they are set in stone, so we all know what to expect and who is responsible for what, and our Seniors and Disabled really apperciate and need us to play along for the most part except perhaps for the upper middle class and the truly well to do.... No carrier is allowed to change or re-write the Medicare Fee Schedule just as we are not allowed to as well.... The rules are pretty clear and rigid and set in stone.... and it is one of the places where the coding and bundling actually adheres to proper coding guidelines so again we all know what to expect, how to properly billing any particular case, and not have to worry about getting hung up on some carrier's lousy bundling policies... So

you can bill an E & M office visit or CPE like code combined with the women's wellcare codes of G0101 & Q0091 for the Breast and Pelvic Exam and the proper collection of the PAP and its chain of custody and get paid and collect for all three... It is one of the better part of Medicare... And another part of reform that was completely ignored by all the Morons who faught over it and claimed to have either patients or doctors as their concern when if fact none of them really did...

That's my two cents for what it is worth....

To: Sent: Tue, March 1, 2011 11:10:14 AMSubject: Re: Secondary billing

Kathy,Thank you. This is how I've handled it in the past but it seems wrong somehow. An even worse example would be if the patient has not met their deductible at all with the well paying primary which would have paid $110.... then the secondary only allows $82 and that is all we could collect. Now, in thinking about this it brings up another question. Why is it that I cannot reduce the patient's primary plan's responsibility (which would be fraud) but another insurance company can?Carla

To: Sent: Tue, March 1, 2011 8:50:47 AMSubject: RE: Secondary billing

My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better

coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?Carla

CyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

[Guest guest]

ahIn MaineMedicaid pays the  20% for the patient

 

Same in Illinois.

 

Tough part is deductible is $130 medicaid pays peanuts so first $130 is free then paid at 80%.  Average charges $250/pt per year so.

 

80% of $120 is $96/250 is 38% of first $250 worth of services.  Based on time $48/hour.  Loss = $90/hour treating medicaid patients for the first 2 hours a year.

 

To:

Sent: Tue, March 1, 2011 2:11:13 PMSubject: RE: Secondary billing

 

,

In Virginia, if a patient has Medicaid as a secondary, they routinely write off the rest of the allowable. So Medicare will pay the 80% (after the deductable) and Medicaid (claiming that the Medicare 80% is already more than they would pay) writes off the 20% and states clearly that the patient is not responsible for this. So in Virginia, accepting patients with Medicaid as a secondary automatically means you will be paid 20% less than the Medicare allowable.

 

From: [mailto: ] On Behalf Of Pratt

Sent: Tuesday, March 01, 2011 2:02 PMTo: Subject: RE: Secondary billing

 

 

I have not seen any Medicare supplemental plans reduce the allowed amount.  But we have patients with dual coverage that are NOT Medicare beneficiaries, and that is when it gets sticky.  For example, I have a patient with Anthem primary and Blue Shield secondary.  The Anthem allowable is less than the Blue Shield allowable.  So the patient responsibility from Anthem was $3.XX and it automatically forwarded to Blue Shield, which processed the claim incorrectly and didn’t apply the primary allowable and simply pay the $3.xx.  Blue Shield now says the patient is responsible for $7 and that it applies to his deductible.  That is what I billed the patient, who called to tell me that I was not allowed to bill him for more than what his primary said.  Normally, I wouldn’t gripe about this, but I spent more than $3 of my time even looking into it.  The fact

that the patient is griping about paying an extra $3 and change really pisses me off.  So I appealed the BSCA decision so that they would not apply more than the $3.xx towards his deductible.  It’s a matter of principal at this point.  The patient is difficult to begin with and this is not really worth my time.  But this type of crap from patients really drives me crazy.  Makes me want to adopt a policy that we won’t bill secondaries, but our contracts won’t allow that, unfortunately.

 

As soon as we are consistently having a full schedule (we are close – we averaged 8 unbooked appointments in February per week and I want it down to 4-5), we will go non-par with Anthem.  I can’t wait.  They are a total PITA and my worst payer.

 

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Bleiweiss

Sent: Tuesday, March 01, 2011 10:32 AMTo: Subject: Re: Secondary billing

 

 

Wait a second. I'm only half monitoring this thread so forgive if I'm off base here... BUT, some 2nd has deductables and the like as well. Just because someone is NOT paying at all or in full does NOT mean that you are not entitled to the full amount " Allowed by Medicare " .... As a matter of fact, not collecting up to that MAX in any and all cases could be construded as Fraud the times that you accept less here and more somewhere else. If Medicare pays you that $110 or " Allows " it with an 80-20 split so you need to turn to 2nd or patient and get that last 20% from one of them, then if you don't go after it, then you are " accepting " less in those cases... The 2nd may only pay $82 dollars but if the Medicare " Allowable " is $110 and in most cases you would go after and collect that entire $110 between the any and all parties involved, then you must do that consistantly across the board. The 2nd is NOT allowed to suddenly re-write the

Medicare Fee Schedule and Medicare Law.

 

    Now perhaps there is something in this 2nd plan that allows for less than full payment of the claims, like perhaps they are now taking on the role of the primary, 1st carriers. But if allowable is $110 and the one and only carrier that paid in the end paid only $82 bucks (which is not 80% of 110, 88 is 80% of 110, BTW.... so they are not attempting to claim that.... so what every their thinking reason or calculations perhaps intentionally shorting you to see if you notice and if not 100,000 times $6 is a lot of profit now isn't it???) then you are just about obligated by law and contract to attempt to go and collect the leftovers from anyone else in the line of payment, and at this point, that is the " Patient Responsibility " in this case.... so obviously 110 minus 82 equals 28 and you should by law and contract attempting to collect $28 bucks from the patient.

 

    I have never heard of a secondary carrier being allowed to flipantly change the Medicare Fee Schedule just to suit their own needs... The Medicare Deductable is what it is, and some plans pay from dollar one and others have their own deductable and other if and whens for when they kick in as well. But in the end the crap roles down hill and someone, usually the patient gets stuck holding the bag and having to pay whatever is leftover after everyone else has paid according to the proper calculations their fair and agreed upon share based on contract and law, 100% of the Medicare Fee Schedule. Heck I have even had a couple of patients with 3rd carriers who then pick up another percentage of the leftovers like a few teenagers we have whose parents are divorced and they are on both parents' plans.... so this one pays first, then percentages of the 2nd and the 3rd, with only 0.24 cents left to attempt

to collect from the parents after the 3rd kicked in... It can get pretty darn silly sometime and not even worth the cost of the stamp and envelope but we are supposed to by law make a good faith attempt to go after this pimple of a balance or we are officially breaking the law. Insane for sure...

 

     It is one of the main reasons many of us still attempt to cooperate and accept this form of insurance... The rules are pretty clear, we all know the rules of the game, nobody is really allowed to play them or change them, they are set in stone, so we all know what to expect and who is responsible for what, and our Seniors and Disabled really apperciate and need us to play along for the most part except perhaps for the upper middle class and the truly well to do.... No carrier is allowed to change or re-write the Medicare Fee Schedule just as we are not allowed to as well.... The rules are pretty clear and rigid and set in stone.... and it is one of the places where the coding and bundling actually adheres to proper coding guidelines so again we all know what to expect, how to properly billing any particular case, and not have to worry about getting hung up on some carrier's lousy bundling policies... So

you can bill an E & M office visit or CPE like code combined with the women's wellcare codes of G0101 & Q0091 for the Breast and Pelvic Exam and the proper collection of the PAP and its chain of custody and get paid and collect for all three... It is one of the better part of Medicare... And another part of reform that was completely ignored by all the Morons who faught over it and claimed to have either patients or doctors as their concern when if fact none of them really did...

 

    That's my two cents for what it is worth....

 

 

To:

Sent: Tue, March 1, 2011 11:10:14 AMSubject: Re: Secondary billing 

Kathy,Thank you. This is how I've handled it in the past but it seems wrong somehow.  An even worse example would be if the patient has not met their deductible at all with the well paying primary which would have paid $110.... then the secondary only allows $82 and that is all we could collect. 

Now, in thinking about this it brings up another question. Why is it that I cannot reduce the patient's primary plan's responsibility (which would be fraud) but another insurance company can?Carla

 

 

To: Sent: Tue, March 1, 2011 8:50:47 AMSubject: RE: Secondary billing

 

My understanding is you can’t charge more than what the secondary says the patient is responsible for.  Unless you don’t participate with the secondary insurance and then you can charge up the  amount the primary says the patient is responsible for.

 

From: [mailto: ] On Behalf Of Pratt

Sent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

 

 

Typically the secondary will pick up the patient’s responsibility.  If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27.  If Medicare is primary, they should be automatically forwarding the claim to the secondary.  If they don’t, work with your patient.  The patient should go to Medicare and give Medicare their secondary’s information.  But if you do need to file a claim, I would file it for only the $27.  You need to attach the primary insurance EOB.  Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa.  Many times patients tell us that their primary is the one that has better

coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

 

Clear as mud?

 

 

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla Gibson

Sent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

 

 

 

I should know the answer to this but I don't.  Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? 

Example:  I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82.  So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?

Carla

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[Guest guest]

RE Medicare with Medicaid secondary.

Yup, same in PA.

Especially damaging when there's a deductible early in the year, means NO DOC PAY.

I do NOT take "dual eligible" Medicare/Medicaid OR Medicaid straight.

I do take Medicare....

Matt in Western PA

RE: Secondary billing

My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?Carla

CyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

[Guest guest]

RE Medicare with Medicaid secondary.

Yup, same in PA.

Especially damaging when there's a deductible early in the year, means NO DOC PAY.

I do NOT take "dual eligible" Medicare/Medicaid OR Medicaid straight.

I do take Medicare....

Matt in Western PA

RE: Secondary billing

My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?Carla

CyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

[Guest guest]

RE Medicare with Medicaid secondary.

Yup, same in PA.

Especially damaging when there's a deductible early in the year, means NO DOC PAY.

I do NOT take "dual eligible" Medicare/Medicaid OR Medicaid straight.

I do take Medicare....

Matt in Western PA

RE: Secondary billing

My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?Carla

CyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

[Guest guest]

But if the first $200 for the year is the deductible from Medicare, doesn't the pt have to pay? Or if this was a Medicare/Medicaid pt, Medicaid writes it off as the original FULL amount was OVER Medicaid...

RE: Secondary billing

My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?Carla

CyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

-- MD ph fax

[Guest guest]

But if the first $200 for the year is the deductible from Medicare, doesn't the pt have to pay? Or if this was a Medicare/Medicaid pt, Medicaid writes it off as the original FULL amount was OVER Medicaid...

RE: Secondary billing

My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?Carla

CyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

-- MD ph fax

[Guest guest]

But if the first $200 for the year is the deductible from Medicare, doesn't the pt have to pay? Or if this was a Medicare/Medicaid pt, Medicaid writes it off as the original FULL amount was OVER Medicaid...

RE: Secondary billing

My understanding is you can’t charge more than what the secondary says the patient is responsible for. Unless you don’t participate with the secondary insurance and then you can charge up the amount the primary says the patient is responsible for.

From: [mailto: ] On Behalf Of PrattSent: Tuesday, March 01, 2011 10:13 AMTo: Subject: RE: Secondary billing

Typically the secondary will pick up the patient’s responsibility. If the secondary doesn’t cover the primary’s deductible or copay (I’m guessing Medicare?), then they will pay nothing and you bill the patient for $27. If Medicare is primary, they should be automatically forwarding the claim to the secondary. If they don’t, work with your patient. The patient should go to Medicare and give Medicare their secondary’s information. But if you do need to file a claim, I would file it for only the $27. You need to attach the primary insurance EOB. Even if the patient doesn’t have Medicare, the primary should be advised that the patient has dual coverage (for example they have Anthem through the patient’s work and GEHA through the spouse’s work), and vice-versa. Many times patients tell us that their primary is the one that has better coverage (often the spouse!), but typically the insurance co’s will require the patient’s insurance to be primary and the spouse’s to be secondary.

Clear as mud?

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Carla GibsonSent: Monday, February 28, 2011 5:53 PMTo: Subject: Secondary billing

I should know the answer to this but I don't. Can anyone tell me if the secondary payer has a lower allowable than the primary, do I then have to adjust based on the secondary? Example: I was paid by a private primary $110 with something like $27 as the patient's responsibility. Then it went to GEHA as secondary which only allows something like $82. So, do I get to bill the patient for the remainder from the primary or do I write it off per the secondary?Carla

CyberDefender has scanned this email for potential threats.Version 2.0 / Build 4.03.29.01Get free PC security at http://www.cyberdefender.com

-- MD ph fax