Wiki Medicare as secondary question

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Scenario: a patient has a commercial (employer sponsored) insurance as primary with Medicare Part B secondary. The Primary commercial payer has indicated that there is a plan exclusion for a particular infusion drug. Medicare part B does NOT exclude coverage for same drug and infusion administrative services. In this case, since Med B is secondary and the Primary excludes the drug, will Med B pay claim as if it were primary with the 80/20? I am initially thinking no as most secondary coverages only provide coverage if the Primary does but I am unsure when Med B is the secondary.
Thank you for your guidance!
 
facciolk@gmail.com said:
Scenario: a patient has a commercial (employer sponsored) insurance as primary with Medicare Part B secondary. The Primary commercial payer has indicated that there is a plan exclusion for a particular infusion drug. Medicare part B does NOT exclude coverage for same drug and infusion administrative services. In this case, since Med B is secondary and the Primary excludes the drug, will Med B pay claim as if it were primary with the 80/20? I am initially thinking no as most secondary coverages only provide coverage if the Primary does but I am unsure when Med B is the secondary.
Thank you for your guidance!
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To confirm whether Medicare is the patient's 2ndary or primary plan, you must check eligibility. The commercial plan should be able to tell you but definitely CMS will tell you. If the commercial plan is primary, then you will bill the procedure to the primary for the denial. Once you have the denial you can bill it to Medicare 2ndary. Hope this helps. Vanessa Moldovan
 
vanessamoldovan said:
To confirm whether Medicare is the patient's 2ndary or primary plan, you must check eligibility. The commercial plan should be able to tell you but definitely CMS will tell you. If the commercial plan is primary, then you will bill the procedure to the primary for the denial. Once you have the denial you can bill it to Medicare 2ndary. Hope this helps. Vanessa Moldovan
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Thank you Vanessa - to confirm - patient is eligible under both plans and Med B is def secondary so that is the good news. The primary will deny drug a plan exclusion - so no coverage at all under primary. As someone newer to billing, I just wanted to be sure if upon that reason for denial Medicare B would pay regardless?
 
facciolk@gmail.com said:
Thank you Vanessa - to confirm - patient is eligible under both plans and Med B is def secondary so that is the good news. The primary will deny drug a plan exclusion - so no coverage at all under primary. As someone newer to billing, I just wanted to be sure if upon that reason for denial Medicare B would pay regardless?
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There is no guarantee, but I think they should pay if it’s a covered benefit .
 
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