Optometry Coding & Billing Alert

Question: I-m not always sure what to do when a patient comes in with a primary and secondary insurance and both indicate to collect a copay. I-ve been told to always follow the instructions of the primary insurance pertaining to copay -quot; is that correct?


Illinois Subscriber

Answer: Collect the lower of the two copays. If one insurer lists no copay, you shouldn't collect any. If one lists a $20 copay and the other one lists a $5 copay, you would collect $5.

By contract, you aren't allowed to collect for anything that exceeds the lowest approved copay. Bill for the visit based on the situation:

If the primary insurer has the lower copay: When you file the claim, always bill the primary insurance first and wait to receive your payment. Once the claim has been adjudicated, you should file the claim with the secondary insurance. Attach the original completed claim from the primary with the original billed amount and a copy of the primary's EOB. The expectation is that the secondary carrier will pay for the difference between its copay and the lower primary's copay that you already collected.

If the secondary insurer has the lower copay: Still file the claim with the primary insurer first. Once you receive payment, file the claim with the secondary insurer, attaching the primary's completed claim and EOB. You will be expecting a denial since the secondary's copay is lower. Even if you just get a denial back, it verifies the coverage and lets you know it's an active policy to consider as part of the patient's guidelines.

Also, sometimes copays change and patients fail to carry the most current insurance card. Receiving a denial can alert you to changes in copay that you might not already be aware of.