medical billing answers

Secondary Medicaid/
Commercial Insurance

Question: I do billing for a Primary Care physician and I have the following questions. I would appreciate very much any answers/insight you could provide.

  1. We have many situations where Medicare is primary and Medicaid (Illinois Medicaid) is secondary. When we receive 80% of the allowed amount from Medicare, we bill Medicaid. However Medicaid determines no more payment is due since Medicare already paid more than the Medicaid- allowed amount. In this case can we bill the patient for the 20% oustanding amount?
  2. We also have patients that have commercial insurance for both primary and secondary (both PPOs). When we have received an EOB from Primary showing an outstanding patient responsibility and we bill Secondary, we typically receive an EOB from Secondary showing a lower allowed amount than the primary. I have the following questions:

    • Are we obligated to adjust-down the allowed amount for the claim from Primary's allowed amount to Secondary's allowed amount?
    • If the patient-responsible amount shown on the Secondary EOB is less than the patient-responsible amount shown on the Primary EOB, are we obligated to adjust the patient-responsible amount to match that shown on the Secondary EOB? Say, the co-pay for the Primary is $20 and the seondary is $15, are we obligated to charge the patient $15 for co-pay or can we leave it at $20?

Answer: Let's answer these in order.

1. No, you can't bill patients for any balance after Medicaid, unless Medicaid has given specific permission to do so (such as spend down amounts or non-coverage). However, you should still bill Medicaid for the rejection, as you may be able to submit that information for Medicare Bad Debt later on and get some kind of reimbursement for it.

2a. If the secondary insurance company is one that you have a contract with, then yes, you are obligated to adjust down that amount if they haven't given you permission to bill the patient for a portion of it. If you don't participate with them, though, then you can bill the patient for that amount.

2b. This is the same answer as the first, that being that it's dependent upon whether your facility is contracted with the secondary insurance company or not.

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