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YOUR GUIDE TO COORDINATION OF BENEFITS AND WHO PAYS FIRST<\/strong><\/p>\n Having issues with getting reimbursed due to reimbursement disputes between payer groups? Wondering who to bill first?<\/p>\n This question comes up a lot in the field, which tells me, dear reader, that you may be experiencing frequent circumstances in which your Medicare beneficiary patients fall into one or more of these categories:<\/p>\n In each of the above situations, Coordination of Benefits kicks in, which is the theme of our September article.<\/p>\n According to eHealth, Coordination of Benefits by definition is: \u201cWhen a person is covered by two health plans, coordination of benefits is the process the insurance companies [payers] use to decide which plan will pay first for covered medical services and what the second plan will pay after the first plan has paid. Coordination of Benefits prevents duplicate payments for the same service on the same date of service, and helps keeps the cost to the patient affordable.\u201d<\/p>\n Let\u2019s look at each of the above circumstances, with resolution for proper claims processing and reimbursement according to the Centers for Medicare and Medicaid Services:<\/p>\n 1.)\u00a0 The patient is not working and is 65 and older:<\/strong> 2.) The patient has been in an accident resulting in personal injury<\/strong> 3.)The patient carries a straight Medicare policy with a secondary insurance policy<\/strong> They may or maynot forward to the secondary if the services are billed with a GA modifier (indicating service was a maintenance adjustment), and will not forward if a GZ modifier is billed (indicating a maintenance adjustment but no signed You may need to file the secondary claim for adjudication on the GA adjustment directly to the secondary payer.<\/p>\n 4) The patient carries a straight Medicare policy with a supplemental insurance policy<\/strong> They may or may not forward to the secondary if the services are billed with a GA modifier (indicating service was a maintenance adjustment), and will not forward if a GZ modifier is billed (indicating a maintenance adjustment but no signed Advanced Beneficiary Notice (ABN) is on file), since you cannot bill the patient for a maintenance adjustment without an ABN.<\/p>\n You may need to file the secondary claim for adjudication on the GA adjustment directly to the secondary payer.<\/p>\n 5) The patient has been injured at work<\/strong> 6) The patient and\/or patient\u2019s spouse is working and carries group health insurance<\/strong><\/p>\n What about in non-Medicare situations where there is a minor child listed as a dependent on dual-spouse or parent policies?<\/strong> I hope that this gives you guidance as you navigate through the payer world of coordination of benefits. Have further questions? We can help. Reach out: For more info on insurance:<\/p>\n *The exception would be if the case is being handled by attorney representation and a settlement is forthcoming. You may bill the liability carrier and seek renumeration, in which case the patient is responsible for repaying the carrier (or Medicare) for services rendered at your office, after receiving settlement. You may bill the patient for their care up front, in which case they would need to wait for their settlement monies.<\/p>\n References: YOUR GUIDE TO COORDINATION OF BENEFITS AND WHO PAYS FIRST Having issues with getting reimbursed due to reimbursement disputes between payer groups? Wondering who to bill first? This question comes up a lot in the field, which tells me, dear … Continue reading \n
\nMedicare Pays First if the patient has Retiree health coverage and is not
\nworking<\/p>\n
\nThe patient\u2019s no-fault insurance or liability insurance\u202fpays first and Medicare
\npays second for services related to the accident or injury. *<\/p>\n
\nMedicare is billed first and will forward their remittance to the secondary payer if the services are billed with AT (Active Treatment) modifier.<\/p>\n
\nAdvanced Beneficiary Notice (ABN) is on file), since you cannot bill the patient
\nfor a maintenance adjustment without an ABN.<\/p>\n==============================================
\nDo you have questions or need help with:
\ninsurance audits
\ncredentialing new providers
\ndebugging complex insurance issues
\ncustomizing billing systems to improve collections,
\npractice appraisals<\/span><\/a>, and more.
\nAsk Lisa<\/span>
\nCall Lisa: (920) 334-4561 (mobile)<\/span>
\nhttps:\/\/pmaworks.com\/lisa-barnett\/<\/span><\/strong><\/a><\/span><\/h2>\n============================================<\/h2>\n
\nThe same applies as with a secondary policy: Medicare is billed first and will
\nforward their remittance to the secondary payer if the services are billed with
\nAT (Active Treatment) modifier.<\/p>\n
\nWorkers\u2019 compensation pays first for items or services related to the workers\u2019
\ncompensation claim. However, Medicare may make a conditional payment\u202fif the
\nworkers\u2019 compensation insurance company denies reimbursement. In this case
\nthe patient is financially responsible but Medicare may pay pending the
\ninsurance company\u2019s review of your claim.<\/p>\n\n
\n
\nThe \u201cbirthday rule\u201d is commonly applied for children covered by two employer group health plans. In this situation, the plan covering the parent whose birthday falls first in the year will pay primary on the children; the other parent\u2019s plan becomes the secondary payer.<\/p>\n
\nlisa@pmaworks.com
\n920-334-4561<\/p>\n\n
\n<\/strong>1) https:\/\/www.medicare.gov\/health-drug-plans\/coordination\/who-pays-first<\/a><\/span>
\n2) https:\/\/www.medicare.gov\/publications\/11546-Medicare-Coordination-of-Benefits-Getting-Started.pdf<\/a><\/span>
\n3) https:\/\/www.ehealthinsurance.com\/resources\/individual-and-family\/coordination-of-benefits<\/a><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"