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Site created on April 18, 2018

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Journal entry by Nathan Bradshaw

The patient is covered under multiple health plans, their own, and their spouses.  Perhaps they may also be eligible for coverage under workers compensation or no-fault insurance because of the event that brought them to your office.

Who is going to pay is not a decision of the patient. “Bill my insurance company, my boss does not want this to be a worker’s comp claim”, or Bill my husband’s insurance, it has a lower deductible.

Physicians engage with numerous patients for numerous reasons, you keep a close eye towards what the patient wants and you keep a keen eye on the diagnosis, however, there are certain things you need to consider, there are certain decisions that you have to make not only in terms of the diagnosis but also regarding financial plans as well. This is a very common misnomer that you can’t make the choice however, these choices are the ones that the patient can’t make. Coordinating benefits follows rules established by the Association of Insurance Commissioners, and they are followed by the plans.  If you follow the patient’s advice, you are inviting your bill to be denied, and then volunteering for an administrative hassle, and perhaps an uncollectable bill.  Don’t become part of such a situation, try to follow the rules.

Determining the Order of Payment, that is who is primary, the plan that pays first.

These rules determine which plan is primary (i.e. the plan that pays first)

  • Any plan that covers the member as a subscriber is the primary plan.  Any plan that covers the member as a spouse or a dependent is the secondary plan.

  • Plans that cover a person as an active employee are primary plans that cover that person as a retiree.

  • The birthday rule determines the primary plan for dependent children.  This means that the parent whose birthday occurs first in the year has the primary plan: the other parent’s plan is the secondary plan for the children’s claims.  The actual year of birth does not matter, only the month and day.

  • There may be some very rare instances where the other plan follows the gender rule rather than the birthday rule, the gender rules apply.  This means that the plan which covers such member as a dependent of a male person shall be determined before the plan, which covers such person as a dependent of a female person.

  • When the parents are divorced or separated, the divorce decree or separation agreement may specify that one parent has responsibility for the children’s medical expenses.  In such cases, the benefits of the plan which covers the child as a dependent of the financially responsible parent shall be determined before the benefits of any other plan that covers the child as a dependent child.

  • In the absence of an agreement or decree that specifies which parent has responsibility for the children’s medical expenses, the plan of the parent with the physical custody pays first; the plan of the patient’s spouse (the stepparent) pays second, and the plan of the natural parent without physical custody pays third.

Be warned: When a plan becomes secondary, the patient engagement may still subject to the same rules regarding prior authorization for certain treatments and all other rules for prior authorization, and coverage.

In 2010 NYS implemented regulation to prohibit insurers and HMOs from denying a claim on the basis that they are coordinating benefits unless the insurer or HMO has a reasonable basis to believe that the enrollee has other coverage which is primary.  In addition, these regulations provide that when a plan lacks current information from an enrollee regarding other coverage, it can request information from the enrollee and allow the enrollee 45 days to submit it.  However, if the enrollee fails to submit the information within 45 days, the plan must proceed with processing the claim and cannot deny the claim based on the enrollee’s failure to provide the requested information.  In other words, if you are advised that another payer is primary, and it is not identified, and the claim is denied, send an NYS Department of Insurance Complaint.

After you have billed the primary carrier, you can bill the secondary for the balance, however that secondary will likely be subject to not only authorization and eligibility rules but also its copays and deductibles.  Generally, there are few dollars to be collected from the secondary. 

Therefore, consider a contingent credit card, authorized to be billed for any balance after the primary and the secondary have paid their allowable.  And don’t get involved in your patient wants to debate the levels of payment that each plan made, you will have to pass that responsibility back to the patient or spend hours of your time for little gain.

Author Bio:

Nathan Bradshaw is a health enthusiast, talented author, celebrated podcaster and a poet who is now the co-editor and imaginative contributor of well reputed electronic health record company catering solo provider ehr to large-scale practices with a background in collaborative care networks and artificial intelligence. Nathan Bradshaw works from a creative wellspring that shows no signs of running dry. 

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