Wiki Coordination of Benefits

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If patient has a primary and secondary insurance and the physician is contracted with both insurance companies which allowable to you go by?

Addl note. We have different fee schedules for both the primary and the secondary insurances. Is it mandatory to go by the primary insurance companies allowable?
 
You would go by the allowable for both insurance companies. Due to the contract with both insurance companies your provider would be obligated to bill both insurances. You would always bill the prime first, they will process it accordingly and roll the rest over to the secondary insurance. If the primary has paid more than the secondaries allowable the secondary will process it and the EOB will let you know to write off the claim due to contractual obligations. If the secondary pays more than the primary you will see an additional payment but you would have to submit claims to both insurance companies for processing.
 
I also found out recently that if the secondary carrier has no stipulation regarding how secondary claims are processed, and they have indicated the service is inclusive, you have to adjust the charge.
In certain circumstances if Medicare denies, and the secondary will only pay IF Medicare pays, we have to adjust off the entire charge.
 
You would go by the allowable of the primary payer. The secondary exists to reduce the member's liability remaining from the primary payer, if dollars are available after the payer determines what it would have paid had it been primary. (dollars in excess of paying the member liability are considered a savings to the payer and/or group)
 
dhouston1870 said:
how are patient balances handled if they have not updated coordination of benefits. Are they written off to bad debt or sent to collections?
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That’s a business decision for your office to make. It’s normally the patient’s responsibility to update COB with their payers. If you’ve already contacted the patient and asked them to do this and they still haven’t, then I would probably refer the account to collections. But every office needs to have its own policy for this as referrals to collections can negatively impact your providers’ patient relationships.
 
It is the patient's responsibility to update their COB. We will notify them if we get a rejection due to that reason. If they fail to update it, the balance becomes their responsibility. The best you can do is let the patient know and ultimately, it's up to them to get it straightened out.
 
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