Primary/Secondary insurance snafu

[Beartracks]

Seeking advice... I'm scratching my head at how often medical providers will screw up insurance claims when you have two insurance plans. In our case, I have ins through my employer, a Fed agency, and my retired spouse also has a Medicare replacement plan. Because she's on my fed plan, it is primary for her for medical claims; normally (that is, if my employer plan was not Fed) her Medicare replacement plan would be primary. This is a constant source of confusion for medical providers.

Anyhow, in one instance, a $3000+ surgical claim was submitted to my plan from an out-of-network provider, and my plan paid for around 30%, but they sent the check to me. I've held onto it as it was my intention to file a grievance with the insurance to see if I could get them to pay in-network rates. As other life stuff continued to happen, I never got around to doing so, although I did manage to call the provider and tell them about the secondary insurance. The provider then filed the ENTIRE amount against the Medicare replacement plan, and they paid nearly 90% of the claim!

So now I have this undeposited check for about $950 and a bill from the provider for about $310.

What do I do? Obviously the primary check will more than cover the remaining balance, but I would have to deposit it in order to pay the bill. I suppose I could pay the bill, and then send the rest back to the primary insurance, but then that would raise flags and issues between the two insurance companies as to who should have paid how much.

Any suggestions? I think keeping the extra amount wouldn't be right.

===========

[rzemanfl]

1. If you are thinking about what is "right" you are not understanding the rules in

Trumpist Dumbfuckistan. $ is not returned in a kleptocracy.

[Dragonfly64]

2. I've managed a medical office for 23 years

and I handle the insurance. Because the provider was out of network your primary insurer sent payment to you and they expect you to be billed by the doctor, so that payment is correct. The real question is whether the Medicare claim was handled properly. Medicare Part B ordinarily pays 80% of allowed charges (after deductible) with the remaining 20% due from the patient or a secondary insurance policy. Since her Medicare is secondary coverage, it's not surprising that they would pay the balance AFTER the primary payment if the balance doesn't exceed their fee schedule. The big question is whether Medicare is aware that your wife has a primary insurance and, if so, did the doctor's office file the claim to Medicare along with the primary benefit information? Any over-payment would more than likely be due to Medicare and the responsibility of the doctor. If I were you I would get a copy of the Medicare explanation of benefits (eob) to see how they processed the claim.

Also - if there are other in-network providers in your area then your primary insurer is probably not going to reprocess the claim as if it were in network. They usually only do that if there is nobody in network available in your area or if it was an emergency situation.

[Beartracks]

4. Im pretty sure the Medicare plan is aware of their secondary status.

Since Medicare plans are usually primary, a lot of doctors will submit claims to them first, and the Medicare plan has refused to pay because they know they're secondary for my wife.

I suppose I could contact the Dr in this case, and ask them if they did indeed submit the entire amount of the procedure to the secondary insurance (which, maybe they did since they hadn't gotten the primary payment yet). Maybe make them aware of the mistake if that's what they did. But then part of me also thinks it's not my job to make sure they do their job right... I just don't want other people's screw-ups to come back on to me - like, insurance fraud!

As someone who's done this kind of work before, what do you think I should do?

[Dragonfly64]

5. You're right - it isn't your job to oversee them,

but the doctor's office deals with a lot of patients and their insurance and you only have to handle your own. As diligent as we are, insurance coverage and benefits change constantly and most people don't know what their own plans cover. If you don't feel that the doctor's staff is going to be much help then I would call Medicare and ask them about the processing of the claim. Did they process it as secondary coverage? Even though they know that they are secondary, I have seen Medicare pay as primary even though they aren't. Did they receive the primary insurance explanation of benefits? Basically, the following:

What were the submitted charges?
What was the Medicare allowed amount?
What does Medicare show that the primary insurance paid? (Did they receive the primary insurance payment info?)
What adjustments did Medicare make, if any?
What did Medicare pay?
What, if any, is the patient responsibility?

Is it possible that the primary insurance originally paid nothing because it was out of network and THAT was the information that Medicare based it's payment on? I would definitely want to see the primary processing to see how they came up with their payment and if it was a result of a reprocessing of the original claim. It should be easy to go on the primary insurer's website and view your explanation of benefits. Then I would call Medicare with the questions above.

[Beartracks]

6. Thanks for the suggestions. Even though I was out-of-network...

.. for the primary, they did pay, but just a lower percent. My original plan was to a) contact them to see if they would re-process at in-network rates owing to the nature of the medical emergency and the specialist we needed; and b) get the provider to remember to submit to the secondary insurance, too. Surely the provider was aware that the primary had paid SOMETHING to me, so I don't know why they would have submitted the total original claim amount to the secondary... But perhaps I'm mis-remembering the order in which things happened.

I'll try to follow-up on this next week. I've got their big check burning a hole in my pocket. lol

==========

[LakeArenal]

3. I think insurance is purposely confusing and incomprehensilbe..

I address all my concerns to my insurance agent and she fixes them. Not sure for whose benefit things get fixed, but at least no one is demanding anything from us once she fixes things.

Good luck with that..


Single Payer!!!!