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Do We Have to Collect Copays for Medicare Patients with Secondary
Insurance Having Specialty In-network Copay?


    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
    file).

    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
    information;
    (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
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