Optometry Coding & Billing Alert

Question: Medicare has denied a claim stating that another payer is primary. That payer is Blue Cross Blue Shield, with whom our office does not participate. Am I required to file a claim with them and get a denial? Then what? Do I try Medicare again, or can I bill the patient?


New Mexico Subscriber

Answer: Mistakes happen, but if your office is not a provider for a patient's primary insurance, you should inform the patient of this and give him the option of going elsewhere. However, patients often don't understand that Medicare may not be their primary insurance. If the patient did not inform your office of his primary insurance, then he is responsible for any fee not paid by Medicare or his primary insurance.

Since you agreed to see the patient in your office, you need to bill the primary insurance, even though you are not a participating provider. In this case, the primary insurer may not pay at all, or they may apply the charge to the patient's out-of-network deductible. If the primary insurer sends you an explanation of benefits (EOB), you can then submit that to Medicare to try to get payment. Medicare will not accept any secondary claim without an EOB.

Smart: Make a reasonable effort to determine who the primary insurer is. Tip: Photocopy the patient's Medicare card as well as his secondary card. If the secondary card is from an insurer that you know provides both primary and secondary coverage, interview the patient to try to determine which is which. When in doubt, call Medicare.