Wiki Secondary payer applying payments as a whole

[rmjanowitz]

I'm having an issue where a secondary payer is refusing to process claims line by line, but instead is calculating the COB amount, then subtracting it from the primary payer amount, and then applying the payment evenly across the claim lines. I haven't experienced any other payer doing this, so I'm confused as to why this is allowed.

Example:
Primary Payment

HCPCS	Billed	Allowed	Deduct	Coins	CO-45	Primary Payment
L1234	$500.00	$200.00	$200.00	$0.00	$300.00	$0.00
L5678	$300.00	$150.00	$0.00	$30.00	$150.00	$120.00
						$120.00

Secondary Payment = Secondary allowed - Primary Paid = $150.00 - $120.00 = $30.00

HCPCS	Billed	Allowed	Deduct	Coins	CO-45	2ndary Payment
L1234	$500.00	$100.00	$0.00	$0.00	$400.00	$20.00
L5678	$300.00	$50.00	$0.00	$0.00	$250.00	$10.00
		$150.00

The secondary payer's only response has been "That's our policy." What would you do in this situation?

The way I've always seen the secondary apply payment (for Medicaid plans) has been:

Secondary Payment

HCPCS	Billed	Allowed	Deduct	Coins	CO-45	2ndary Payment
L1234	$500.00	$100.00	$0.00	$0.00	$400.00	$100.00
L5678	$300.00	$50.00	$0.00	$0.00	$250.00	$0.00

 

[haraml7]

I would post it as is. They paid what was left over so your claim will come out as $0.00 remaining. Unless you have a software that may not allow you to do that, but you should be able to post the amount to the claim and as long as it is $0 your system should recognize that. I hope that helps.

 

[rmjanowitz]

I would post it as is. They paid what was left over so your claim will come out as $0.00 remaining. Unless you have a software that may not allow you to do that, but you should be able to post the amount to the claim and as long as it is $0 your system should recognize that. I hope that helps.

I'm confused as to why you would write off 80% of that claim line when you're essentially being underpaid for that service. If you write off claim lines like this, you can expect to not be reimbursed for some services ever. Say for instance, if the primary payer paid $150.00 for the second line, and nothing for the first line, the secondary payer would also pay nothing for the first line. Now you have one claim line that was never reimbursed.

 

[haraml7]

I understand where you are coming from. Trying to get the insurance companies to do the right thing is really hard. I had to learn when they say "that's their policy" that is how they will process the claim. Is that one particular insurance processing alot of claim like that as secondary?

 

[rmjanowitz]

I understand where you are coming from. Trying to get the insurance companies to do the right thing is really hard. I had to learn when they say "that's their policy" that is how they will process the claim. Is that one particular insurance processing alot of claim like that as secondary?

They're a new payer of ours and the only one that processes claims this way. It is a Medicaid integrated plan in California. Even Medicaid does not process claims this way. We haven't worked with them prior to this year, so it's a new issue and I'm unsure of how many claims this is going to end up affecting.

Our contract states they will pay "one hundred percent of the current DHCS fee-for-service reimbursement." We are a fee-for-service provider, so as far as I'm concerned, barring any other regulation or guideline, each service is to be paid at 100% of the current DHCS fee-for-service reimbursement. If the primary is paying nothing, then I am expecting 100% of the current DHCS fee-for-service reimbursement and whatever internal claims processing procedures that their claims department is using to adjudicate claims needs to be brought in line with that, not the other way around.

I'm wondering if there's any guideline, regulation, or claims norm that I'm missing, because this doesn't seem like common practice. In fact, it seems like a way coerce providers into really bad, abusive, or fraudulent business practices, if the only way to make sure all services on a claim are processed correctly is to (1) bill each line on a separate claim or (2) only see patients for one service per day.