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Medicare and Medicaid

Can a Medicare provider bill a secondary insurance for the Medicare deductible?


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2008-12-23 15:54:42
2008-12-23 15:54:42

This is directly from the Medicare and You 2009 Book: When you have other insurance, there are rules that decide whether Medicare or your other insurance pays first. The insurance that pays first is called the "primary payer" and pays up to the limits of its coverage. The one that pays second, called the "secondary payer," only pays if it covers any of the costs left uncovered by the primary coverage. If you have other insurance, tell your doctor, hospital, and pharmacy so your bills get paid correctly. If you have questions about who pays first, or you need to update your other insurance information, call Medicare's Coordination of Benefits Contractor at 1-800-999-1118. TTY users should call 1-800-318-8782. You can view the details here:

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they can't actually "require" it but any insurance can contract with Medicare to be secondary, provided both parties agree

Yes, If medicare pays more than the secondary insurance allows for a charge, the secondary insurance pays nothing. The balance is written off to a contractual allowance that is agreed upon between the provider of service and the insurance company via contract.

If you have medicare and you are a dependent on your spouses medical insurance policy then you would be primary under your spouse and Medicare would be secondary payor. There are a few circumstances where Medicare would be primary but very few (your spouse is covered under COBRA, the group is less than 20 members, or you have end stage renal disease.) Medicare is 99.99 % always secondary because it is a government program (much like Medicaid.) I hope this helps:) Evan

The EOB (Explanation of Benefits) is what explains Medicare's payments and denials. Sometimes it is referred to as an EOP (Explanation of Payment). This document will show all items filed on a particular claim for a particular provider. It will show which items were covered or noncovered and why, which items were denied and why, and which items were paid. It will also show the patient's responsibility as far as deductible and coinsurance goes. If the patient has a Medicare supplement or just a secondary plan and Medicare is aware who you have chosen, they will "crossover" the claim to the secondary. This means they will automatically send a notification to the secondary payor to let them know how much Medicare allowed (the total amount the provider should receive from Medicare, other insurance companies and the patient), and how much is being left to the patient/secondary.

Consult your mother's insurance or Medicare provider.

The patients responsibility is the dollar amount indicated on the MRN (Medicare Remittance Notice) due to the doctor (rendering provider). This amount is typically 20% that Medicare does NOT cover, and solely the responsibility of the patient when one has Medicare as their primary health insurance carrier, and NO supplemental or secondary insurance. By law the patient MUST pay this 20% co-pay amount indicated by Medicare. The patients responsibility amount may vary according to the level of visit, or deductible due, all indicated by their insurance. If a Medicare member has any questions regarding how much they owe to a doctor at any time, they should call the number located on the back of their Medicare identification card.

If the provider is out of network or not contracted with the secondary insurance, they do no have to bill the secondary and the patient is responsible for the balance (if any) owing

Medicare does offer coverage for skilled nursing facilties. In order to find out if Medicare will pay as your secondary, the provider needs to submit it to Medicare. This statement is from the website: Medicare providers must submit claims (bills) to Medicare for you, whether Medicare is your primary or secondary insurer. For Medicare to process a claim as a secondary payer, the provider must give your primary insurance information to Medicare. You may also consider calling 1-800-Medicare for information about secondary coverage. If you do, remember from Nov 15th to Dec 31st is a busy time for Medicare so it may be difficult to reach them. One more hint to save some frustration: If BlueCross BlueShield has already paid the amount they were supposed to pay, calling them won't really help you because their job is done. Now the remaining bill is between the provider and Medicare.

Primary has to process and pay claims first then secondary will process and pay leftover expenses according to their policy provisions. The secondary sometimes excludes payment towards a primary policy deductible.

I had retired from my employer before 65. I continued the retirees' group health insurance. When I turned 65, my employer required me to take Medicare as my primary insurance. I could stay with the group, but it would "coordinate" benefits with Medicare. My experiences with my providers have changed. Before Medicare, my providers would bill my insurance and take their payment. I would pay the deductible and co-insurance. With Medicare, my providers will bill Medicare but not accept their payments. So, Medicare sends me these silly paper checks (they will not use electronic deposits). The provider can bill 115% of the Medicare approved amount. My group plan then pays based on the 115% amount (less any deductible and co-insurance). They also send to me their silly paper checks. (All that happened is that I turned 65 - now I get silly checks and a bookkeeping nightmare). I take the paper checks to the bank and then pay my providers electronically. One time I had services from a provider that participated with Medicare. Medicare paid (I got their paper MSN after about four months). My group plan paid. The provider asked me to pay the balance. Worked pretty smooth - except the provider charged me for items I did not receive. They said since Medicare paid them based on a "DRG" (a payment scheme based on the primary services delivered - without worrying about cost), they could not rebill and it would not make any difference if they could. Again, before I turned 65, it was easy to point out an error to my group insurance and it got fixed quickly. Medicare takes a long time to even understand the question. So, ask your employer or insurance company how they work with Medicare. Then, hope that you can keep them as the primary payer. Also, if you have to go with Medicare, let's hope that your providers accept Medicare.

The deductible is the amount of money that you will need to pay out of your pocket before the insurance company will pay for the surgery. Once you have proof of paying the deductible, then the provider will bill the insurance company, and they in turn will pay the provider according to how the policy states it will pay. Check your policy to see if it's an "80/20" plan or something different. An 80/20 plan means that after you pay the deductible, the insurance company will pay 80% of the bill and you will pay 20% of the bill.

In Illinois, a provider who accepts a patient as Medicaid cannot bill that patient for anything for which Medicaid would have paid had the provider timely and properly billed Medicaid.

I will use for example someone on MEDICARE. They have paid into their medicare insurance and have both parts (thus eliminating confusion of part a, part b). First the bill is sent to the Medicare insurance provider, who will have an allowed amount and then of that what they will pay. The billing medical source credits what MEDICARE paid and then submits the balance to the 2nd or CO-INSURANCE. As a whole, if MEDICARE pays 90%, the CO-INSURANCE picks up the balance of 10%. These figures were used as an example. You will have to know your own breakdown of what percentage is paid. Remember is is on the ALLOWABLE or APPROVED amount, not the whole billing. Most insurance such as MEDICARE and personal insurance through a work place, have a provider adjustment. Then the % is taken from there. PRIVATE holders of medicare and co-insurance my not have the luxury of an adjustment of cost. And will have to cover what is left.

Secondary insurance will not pay the claim but the remaining charges should not be billed to the member/patient. Provider of service should write off the patient responsibility that primary insurance applied.

Once Medicare has "adjudicated" the bill, MediCal's payment will be based on their policy and the patient's eligibility on the date of service.

Yes, and you want them to because if they are paid out of order then it will be a mess to correct.

Having the same insurance company twice, as a primary and secondary, means you are paying twice for the same insurance policy. They probably will not cover the same thing twice, or they may treat it as two different policies and may treat it that way. If they were two different policies, The primary would deal with any deductible and copay before fulfilling its contractual obligation and so would the secondary policy depending on the wording of the contract. Unless there is no deductible and copay, or if one policy covers the deductible/copy of the other, there will still be a balance you owe. There is also the situation where your medical provider will not accept or fully participate in your insurance policy, in which case you may owe the difference between the doctors bling amount and what was paid by the insurance(s).

Yes. Original Medicare does not require you to obtain a referral before seeing a provider, but it does expect you to see a Medicare provider.

deductible mean patient should pay pearticular amount to the provider, before provider start treting the patient.

I think not. It seems unlikely that a provider would be limited to the rates of an insurance carrier, such as Medicare, of which the patient is not a member.

Yes, under most circumstances it will. Medicare has a set amount for these types of services, no matter what they charge. Medicare allows the provider to bill a certain discounted amount to the patient or insurance company.

No, it's fraudulant. It's not practical, the secondary insurance should pay the remainder of the cost the primary insurance doesn't cover.

This mainly depends on the state and type of insurance that you have. Some insurance companies waive the deductible for windshields and/or all glass that is in a car. Also, if you live in Florida, Kentucky, Maasachusetts, or South Carolina insurers are required to charge you no deductible to replace your windshield. Discuss this with the insurance your insurance provider and also state laws.

Let me tell you what happend to me. I hope that this helps. I used to be covered by two insurance companies. My primary insurance company was through the company that I worked with. My secondary was with the company that my husband works with. When a claim was filed with my secondary insurance company they wanted to know how much my primary insurance company paid for and until then they would not pay anything. So I had to submit to my primary insurance company and once they paid some then the secondary would. I hope that this helped:) * Yes. A claim must always be made with the primary insurer first.

You should or you customer WILL be PISSED for having to do the leg work of getting the information of what the primary paid and getting it to their secondary.

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