When Medicare is a Primary Insurance for the patient, the patient's part
responsibility (coinsurance/deductible) normally crosses over to its secondary
insurance for secondary coverage (if Medicare has the secondary insurance on
As you will notice on your Remittance advise, it'll say: "Claim Information
forwarded to: (insurance company here)". Meaning, Medicare will forward the
information to the secondary insurance. If not, try to find out if there is a
secondary insurance for the patient, then you need to send the paper claim (using
the HCFA 1500 form for Office/Provider/Professional Claims) to the secondary
and attach a copy of the Medicare EOB (explanation of benefits). If your practice
management software is capable of doing this by electronic submission with
attached copy of the EOB - much better!
After you submit the claim to the secondary insurance, the secondary insurance
EOB will then tell you if there is a copay being applied towards the patient being a
secondary insurance after Medicare.
You will then obviously collect that copay based on your contract with the
secondary insurance company (and this is also based on the patient's contract
with his/her secondary insurance). Medicare patients are mostly aware of their
responsibility after the secondary insurance picks up.
Bottom line here:
(1) Medicare must process (not deny or reject!) the claim first being the primary;
(2) Secondary insurance must then process the claim with Medicare's claim
(3) Then, if there is a copay being applied towards the patient's responsibility --
you have to bill your patient for that copay!
But honestly, I do not collect secondary insurance copay not until the secondary
insurance had processed the claim (after Medicare's allowance!). WHY? because
it is possible that the patient may no longer have an active policy (at the time of
service) with the secondary insurance, or maybe, there is no more copay because
the patient had met his/her out of pocket limit. So to streamline this issue (of which
not all offices are doing it) - you must always check benefits and eligibility for your
patient's primary, secondary or even tertiary insurance coverage!
It may be a lot of work too, but what I do is that, when I am billing the patient a
copay (from the secondary insurance's determination and per the EOB) or even
for their coinsurance! I do my best to attach a copy of the EOB on the statement.
That way, the patient has a copy of the said EOB and he/she will understand why I
am billing him/her.
Useful References: CPT Code Books, CMS Website (www.cms.gov), CCI
Quarterly Updates, CPT Assistant Publications, Diagnosis Code Books