Neurosurgery Coding Alert

Question: Our surgeon did an operative procedure on a patient 11 months ago. We now understand that the patient had primary and secondary insurance at the time. The payer, reported to be secondary then, was actually the primary payer. This means that the secondary insurance company paid us as primary. Are we obligated to refund the money even though it’s been almost a year? Is there a way we can rectify this?

Connecticut Subscriber

Answer: You have now uncovered the error of reporting the secondary payer as primary. Even though it is now a few months since you reported the procedure, you can call the payer and inform about this error. You may however, leave it to the payer to decide the next course of action, if any. The payer may like to work directly with the patient to help find a solution and rectify this erroneous payment.

Your practice should not be held liable: If a patient makes a mistake and gives the secondary payer as the primary, the insurance company will hopefully catch the error and then pay at the secondary rate.

Obviously, in this case, that didn’t happen. If the secondary insurance paid the claims as a primary because it was unaware of other insurance and your practice also did not have any knowledge of the primary payer, then your practice should not be held liable.

Talk to the payer: If a patient presents you with information on what she thinks is her primary insurance, and your practice finds out much later that it was her secondary insurance but you were paid, talk with the payer.