Practice Management 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 - is that correct?

 Illinois Subscriber
 
Answer: Collect the lower of the two copays, says Donna Rachunas of Health Claim Services Inc., a billing service in Haddonfield, N.J. If one insurer lists no copay, you wouldn'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, she says. 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. But, Rachunas says, you never know if the secondary insurer's allowables are greater than the primary's - in which case you might get payment that has nothing to do with the copay. Even if you just get a denial back, says Rachunas, that 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. 
 
Many billing offices feel it's too much work to follow up with the secondary insurance on a claim that's already been paid. That's an office policy that needs to be decided by every practice. "I always remove any 'and-if-but' decisions and say to always bill a secondary, even if there's no balance, to simply get the denial and be sure that our records are in order," Rachunas says. From a billing service perspective, she wishes to be sure she's tried to collect the maximum from all available payers. 
 
Note: Billing offices have various methods for dealing with this situation. Some prefer not to collect a copay at all under the assumption that the secondary insurance will cover it. They find it easier to balance-bill the patient in the event that the copay isn't covered, rather than deal with collecting copays and issuing refunds when the insurer does pay. This is a decision your billing office needs to make based on what's most efficient for you.