Wiki Medicare secondary

[msbiller]

Can someone please help me with Medicare secondary claim questions? The claim was for $152.00 -- primary insurance allows $65.00 ($25.00 insurance payment, $40.00 copayment to patient, $87.00 adjustment). The claim has $40.00 balance and was then filed to Medicare. They paid $77.83. Medicare says patient owes $16.68. Is the primary insurance adjustment reversed? Does the patient owe anything? Medicare tells me that I can appeal the claim to see if it paid correctly...what?? Thank you!!

 

[SharonCollachi]

There are times when Medicare allows more than the primary, and in those instances, yes, the patient owes the difference. Some practices don't collect it, but if the Medicare EOB shows the patient owes it, that's what we go by.

Claim............................................. $152.00
Primary Adjustment.................. -87.00
Balance ..........................................$ 65.00
Primary Paid ..................................-25.00
Balance due from anyone..... $40.00

Medicare allowed....................$119.51 <----- we back-adjust $54.51 (primary allowed of $65 minus Medicare allowed of $119.51)
Medicare paid...............................-77.83
Balance.............................................$41.68
Less what primary paid........... -25.00
Patient owes..................................$16.68

How this looks in regards to transactions:

Before the back-adjustment, the balance is.... $40.00
Add in the Medicare back-adjustment...............+54.51
Balance..................................................................................$94.51
Less Medicare payment................................................-77.83
Patient owes........................................................................$16.68

 

[msbiller]

Thank you!

 

[dbryant96@gmail.com]

I would also make sure that the patient has coordinated their benefits with Medicare. You can determine this by calling the Benefits Coordination and Recovery Center: 1-855-798-2627.