Wiki Billing Question

[Stephanie95]

If patient "A" has primary insurance Aetna and Premera secondary and a clinic billed out a lab code to the primary Aetna that sends a response saying it is CO222 Exceeds the contracted maximum number of hours/days/units by this provider for this period and the EOB says the PT responsibility is $0 and this claim got sent to the secondary INS Premera who paid and also gave a portion to PR would you bill the PT for that amount as the Primary processed with the PT owing nothing as it is CO? Should the provider have written the amount off by the Primary as it was a CO222 and exceeded the contracted amount? Or should this claim have been sent to secondary? Was told by primary INS that we can not balance bill the PT as they denied it with the PT being responsible for nothing.

 

[thomas7331]

If you have a contract with the primary insurance to accept a certain amount as payment in full and they have paid that amount, you certainly can't bill the patient for anything additional. It's OK to send a zero balance claim to the secondary insurance (that way, if the patient has a deductible, they may get credit on the other plan), but I wouldn't expect any additional payment. But secondary payers, in my experience, frequently make errors when coordinating benefits or have strange rules for calculating secondary payments, and some don't even coordinate at all for reasons unknown to me so it is not unusual to see this. My feeling has always been that if a secondary payer pays more than the balance owed by the patient after the primary payment, this is an overpayment and the money should be refunded back to the secondary payer.