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Thread Topic: duplicate coverage
Topic Originator: smbs
Post Date July 9, 2008 @ 4:37 PM
duplicate coverage

July 9, 2008 @ 4:37 PM Reply  |  Email Friend   |  |Print  |  Top

Please somebody clarify for me.
primary ins allowed amount     2nd ins allowed amount
                  $300                              $200

primary paid $250                  2nd did not pay bcz primary paid more than 2nd's allowed amount.
so, we sent to bill to patient for $50 ($300 - $250).  Now patient questioned????  are we right to send bill for the difference??/

steve verno
July 14, 2008 @ 11:31 AM Reply  |  Email Friend   |  |Print  |  Top

What we dont know is:

Are both carriers contract with the proider?  If so, was the allowed amount per the contract requirments?

If contracted, what does the contract specify about COB issues.

Also, if not contracted, what does the patient's polocy say about COB? Some policies may say they dont pay more than the primary alowable or payment.  

Last, have you checked your State COB laws?

For example, with Florida:

FS 627.5235:

2)  A hospital, medical, or surgical expense policy, health care services plan, or self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses issued in this state or issued for delivery in this state may contain a provision whereby the insurer may reduce or refuse to pay benefits otherwise payable thereunder solely on account of the existence of similar benefits provided under insurance policies issued by the same or another insurer, health care services plan, or self-insurance plan which provides protection or insurance against hospital, medical, or surgical expenses only if, as a condition of coordinating benefits with another insurer, the insurers together pay 100 percent of the total reasonable expenses actually incurred of the type of expense within the benefits described in the policies and presented to the insurer for payment.

July 15, 2008 @ 2:07 AM Reply  |  Email Friend   |  |Print  |  Top

thank you for your reply.
providers are contracted with both carriers. Each carrier has their own fee schedule.  
If based on the primary's fee schedule which is higher than 2nd's fee schedule, ; 1st's allowed is $300, and the covereage is 80% ($60 ll be co insurnce), 2nd's addlow amount is $220 and the coverage is 100%.
This 2nd will not pay because 1st paid  more than their allowed amount.  The 20% coinsurance or $60.00 need to be collected from patient.   If the situation is opposit with this example, there will not be patient's responsibility.   This is my understanding.  Is this correct???

July 15, 2008 @ 6:52 PM Reply  |  Email Friend   |  |Print  |  Top

Hard to believe this, the patient paying his premiums to a secondary carrier to cover any deductible or coinsurance from the first carrier and he couldn't even benefit! I am not knowledgeable in health insurance law but my opinion is that it will be unfair to balance bill this patient.. just my opinion.

steve verno
July 15, 2008 @ 7:34 PM Reply  |  Email Friend   |  |Print  |  Top

Every insurance company has their own fee schedule, but what did the provider, in the terms of the contract agree to be paid when rendering services to a patient.  or when aying as a seondary carrier.  That is the answer we dont know.  Without this knowledge, there is no correct answer.

To me, this is more in line as a contract dispute and should be resolved with a lawyer experienced in contract law.

I would not bill the patient due to possible hold harmless clauses we may not be aware of.

July 23, 2008 @ 1:54 PM Reply  |  Email Friend   |  |Print  |  Top

there always contract with each carrier as PPO physician. But I don't think there is any clause for secondary coverage.
If it is Medicare, Medicare fee scheudle dominate. If the 2nd's fee schedule is lesser than Medicare, we are still billing to patient for the balance.
Please somebody clarify this situation????

July 23, 2008 @ 11:29 PM Reply  |  Email Friend   |  |Print  |  Top

Like Steve said, I would also check the State Coordination Of Benefits law.( Try your State Department of Insurance)

Dan Young
July 24, 2008 @ 5:47 PM Reply  |  Email Friend   |  |Print  |  Top

If the provider's contract with the primay carrier states that he will collect the 20%, then it should not matter if the secondary pays or not.  The provider is owed the full amount.  The patient has the obligation to pay for services rendered.

August 3, 2008 @ 8:56 PM Reply  |  Email Friend   |  |Print  |  Top

True, let the patient fights for himself with the 2nd insurance, he might have the right to do so. He is paying a premium to that insurance anyway and therefore he has a contract with the insurance too.

steve verno
August 4, 2008 @ 10:39 AM Reply  |  Email Friend   |  |Print  |  Top

Excellent advice to all, but everyon is correct based on the info provided.

Here is everything in a nutshell so that we all understand and are in the same sheet of music.

In healthcare payments, we have contracts.  There is the basic contract between the patient and their insurance company or the employer and the insurance company. This contract outlines the benefits that are to be provided and how the patient is to be reimbursed when paing for the services they received if the service is a benefit. The contract also specifies the patients out of pocket expenses such as copayments, deductibles and any amounts not paid by the insurance company that they may call their usual and customary.

The second contract is between the provider and insurance company.  That contract should specify how the provider is to be paid and payments when there are cioordination of benefits taking place.  With contracted providers, the contract may specify that the provider submits the claim on behalf of the patient along with specified timeframes for claims submission. It doesnt matter what fee schedule the insurance company may have, the provider is to be paid per the payment terms of the contract.  The allowed amount should be the contract amount, along with the payment less copays, coinsurance or deductibles. The exceptions are with Medicare, Medicaid, and workers comp. With these three types of coverage, the provider also contracts through enrollment documents.  The provider agrees to accept the specified allowed amounts less any copays coinsurance or deductibles.   In some states, Medicaid patients may have small copays such as with Florida, which has a $2.00 copay.  

Providers who are NOT contracted are entitled to 100% of the cost for their services. How the patient pays is up to the patient.  Some patients have insuranc, but how the insurance company pays is based on the contract that have with their member. Regardless of how the patient's insurance pays, the patient is the debtor and must reimburse the provider for those amounts not paid by their insurance company.  

Noncontracted providers are not obligated to submit any claims at all.  That is a patient contract requirement.  Some patients feel that because they have insurancce, it is up to the provider to involve themselves with their insurance company to be paid.  The bottom line is simple; The patient received the medical care. The patient owes the provider for the care and the provider is the debtor to the provider.

with Non-contracted providers, the insurance company may have an established reimbursement fee that they tell the provider they pay to non-par providers, but the secret is:  THE INSURANCE COMPANY IS REQUIRED TO PAY BASED ON THE CONTRACT WITH THE PATIENT.  If the insurance company did not pay the provider based on the patient contract amount, then it is up to the patient to make their debt whole and to appeal the payment of their benefit. It is not up to the non-par or non-contracted provider to appeal a benefit payment.

As medical billers, when reviewing insurance company payments, we should understand how the contracted provider is to be paid.  We should understand how the incorrect contract payment is to be appealed based on the contract.

When it comes to patient contracts, we need to know which laws have jurisdiction.  If benefits are provided by an employer, not a government or church employer, then Federal Law may have jurisdictio over the contract, THis includes the benefits provided, claims process, payment of the benefit and the appeals proces: 29 USC 18, 1003(a); 29 USC 18, 1144(a); and 29 CFR 2560.503-1.  TO know how an insurance company pays the benefit, it helps to read their benefit manual or summary plan description.  How do you do that, You ask the patient for their copy and you make a coy for yourself. If you have insurance, look at your own benefit manual to see how your claim are to be paid and who submits claims when you go ou of network.  

Disclaimer.  The information in this post contains no legal advice  All information is posted for training purposes.

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