# Medicare Secondary's allowance is higher than the primary's



## CatchTheWind (Apr 8, 2014)

Commercial insurance paid at 100% of their allowance, leaving a zero balance.  But patient has Medicare Secondary, and their allowance is much higher than the primary's. Can we bill Medicare to make up the difference in allowances (even though we are participating with the primary)?

And if so, how do we handle the resulting credit that results from receiving the Medicare payment after the balance was already zero?

*Example* (for simplification purposes, I am ignoring the sequestration adjustment):
Primary allows $70 and paid $70. Medicare allows $100, so if they were primary, they would have paid $80.  As secondary they will pay $10.


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## Herbie Lorona (Apr 8, 2014)

I would say yes you would still want to submit the claim to the secondary. Here is some other reasons why you want to still submit to the secondary. I created an adjustment of "Secondary allowed more then primary paid."

Here is what I found from WPS Medicare.

Should I Bill Medicare When the Primary Insurer Paid in Full?
My patient provided primary insurance information and the insurance company paid in full. Do I still need to submit a claim to Medicare?

Medicare recommends you submit the claim for secondary benefits even though there is no outstanding balance. The reasons for this include application of the patient's deductible for allowed services, notification of certain once in a lifetime benefits, recording of certain time restricted services, and allowing Medicare to keep the claim on file. This last one becomes vitally important when the primary insurance company requests the payment back.

The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-05, Chapter 3, Section 10.5Adobe Portable Document Format indicates that a primary insurance take back alone does not constitute good cause to waive the 1 year filing limit. However, if we already have the claim on file, we may be able to perform a reopening. You can find more information on good cause for waiving the file limit and reopening on our website. Please see our Claims and Appeals pages.

http://wpsmedicare.com/j5macpartb/claims/submission/primary-paid-full.shtml


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## CatchTheWind (Apr 8, 2014)

Thanks for the detailed answer and the quote from WPS Medicare!

I'm still troubled by the question (not addressed by WPS) of what if Medicare has the higher allowance and their payment results in your accepting more than the primary's allowance (since, as a participating provider, you are not permitted to balance bill).  Has anyone seen any sources addressing that?


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## MarcusM (Apr 8, 2014)

If your provider has contracted with XYZ insurance to accept their fee schedule as the contractual allowable, then you need to: A. read the fine print to see if you can collect more than their fee schedule for their insured members, but usually you can only collect up to the maximum amount in the contract,  and B. renegotiate your contract ASAP.  To stay in business in the medical field, the Medicare allowables should be your lowest reimbursement for commercial insurance plans. Medicaid is a separate ball game.


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## Herbie Lorona (Apr 8, 2014)

Here is something per CMS website

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/msp105c03.pdf

40.1 - Full Payment by the Primary Payer
40.1.2 - Outpatient Bills, Part B Inpatient Services and HHA Bills

*No bill is submitted if*
-Payment by the primary payer for Medicare covered services equals or exceeds:

   The provider's charges for those services, or

   The current Medicare interim payment amount (without regard to the deductible or coinsurance), or the provider accepts (or is obligated to accept) the primary payer's payment as payment in full (and it receives at least this amount) and the provider knows the individual has already met the deductible.

*A bill is submitted to:*

-Inform Medicare of charges where the deductible may not yet be met. Although Medicare can make no payment, it can apply the expenses to the beneficiary's deductible. A bill is required for crediting the deductible.

So if you are obligated by the primary to accept there payment as payment in full you don't need to submit to Medicare if the pt has already met the deductible. If you are not obligated to accept it as payment in full you can bill to Medicare. Most likely Medicare is going to pay some of the difference and patient still wont be responsible. If you Google MSP Calculator you can see some of the calculators that the different jurisdiction's have to help determine payment on MSP claims.


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## CatchTheWind (Apr 10, 2014)

MarcusM: I wish it were the case! In most parts of the country, and for other specialties, that is probably quite true.  But for dermatology practices in South Florida, the insurers will not negotiate.  It's "take it or leave it."

Herbie, thanks for your second post; that's my answer!


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## Herbie Lorona (Apr 11, 2014)

No problem. Glad to help!


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## JesseL (Apr 29, 2016)

Would like clarity on this.

We are in-network with OXFORD.

We claimed 170 to Oxford.

Oxford allows $67.01, copay 25, oxford pays $42.01.

Submitted claim to Medicare with the adjustment codes co-45 $102.99 & pr-3 $25.

Medicare finalizes the claim as allows $83.19, patient deductible $83.19, they subtracted the $42.01 from the medicare deductible and says patient's responsible for $41.18.

Does this mean we ignore medicare's $41.18 patient responsibility since we're in-network with Oxford and just collect $25 from the patient?

OR

Do we collect $41.18 from the patient because we are in-network with Medicare and ignore our contract with Oxford?

I called Medicare about this claim and they said patient's responsible for $41.18 even though we're in-network with Oxford.

We're in network with both Oxford and Medicare so I'm not sure what to do here.


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