Wiki DOUBLE COVERAGE ISSUE PROCESSING

[kcowan]

CAN ANYONE EXPLAIN TO BE HOW TO FIGURE OUT WHAT A PATIENT OWES WHEN THEY HAVE 2 INSURANCES, ALL THE INSURANCE DO IT DIFFERENT. YEARS AGO IF THE PRIMARY ALLOWED MORE THEN THE 2ND THEN THE 2ND PAID, BUT IF THE 2ND ALLOWED MORE THEN THE 2ND THEN THE 2ND DID PAY ANYTHING. BUT NOW IT IS ALL DIFFERENT. I HAVE A PATIEN THAT HAS BCBS PRIMARY AND CIGNA 2ND AND I AM FIGHTING WITH CIGNA BECAUSE I BELIEVE THAT CIGNA OVER PAID. I HAVE INCLUDED THE EOBS THERE HAS TO BE SOMETYPE OF FORMULA I CAN GO BY?

 

[lipedenise@gmail.com]

There is not necessarily a formula and much depends on if your provider participates with both payers. It appears they do. This is frustrating because each policy is written differently. Obviously, Cigna's policy is written that they will use their allowable rates on a secondary claim rather than just picking up the deductible, co-pay, co-insurance. Just write off as contractual the difference between billed and paid and call it at that. I believe the patient owes nothing. Your provider got paid 61% of billed charges which is amazing considering 45% is average.

 

[csperoni]

I would certainly not be fighting with an insurance company trying to pay them back if they state it was paid correctly. Yes, if you know there is an error, you must correct it. But it simply appears the Cigna allowable is much higher than BCBS. Cigna took their allowable, applied co-insurance, deducted what BCBS and sent you the difference.
Yes, if Cigna processed as primary, then you definitely have an overpayment. But Cigna was aware of the BCBS payment and deducted that from their payment. I would call it a day.