Optometry Coding & Billing Alert

Question: When patients have private insurance in addition to Medicare, is there an easy way to determine whether Medicare is the primary or secondary payer? It's hard to keep straight, and sometimes the patients don't know, either.


Washington Subscriber

Answer: Medicare will always be the primary insurer for beneficiaries not covered by other insurance. The quickest rule of thumb to determine primary or secondary status is to ask whether the patient or his spouse is still working. If the answer is yes, ask whether the private insurance is through the employer. If yes, then the private carrier will most likely be the primary.

There are several exceptions to that rule, and it can be hard to keep all the variables straight. For instance, if the patient is 65 years or older and is covered by insurance through a current or former employer, Medicare is secondary - unless the company has fewer than 20 employees.

Medicare has published a fact sheet for billing staff titled "When Medicare Is the Primary Payer." It includes a table of the common conditions that determine whether Medicare is primary, as well as information on what to do if the private carrier denies a claim. To download the fact sheet, visit http://www.cms.hhs.gov/medlearn/msp_4a.pdf.