Medicare provides health insurance coverage for more than 55 million Americans — over 15 percent of the population — and that number is expected to rise to about 79 million by 2030. Individuals who are 65 years or older, disabled, or have end-stage renal disease are eligible for Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). However, many patients also have another form of insurance as well. That can make it difficult for medical billers to determine which payer is the primary insurance provider and which is the secondary (or tertiary) insurance provider.
Determining Whether Medicare is the Primary or Secondary Payer
When a patient has multiple forms of insurance coverage, the primary insurance provider is billed first and pays up to the limits of its coverage. Then, the remaining bill is submitted to the secondary insurance provider, which may pay for some of the costs that are not covered by the primary payer. Usually, healthcare facilities rely on patients to report whether or not Medicare is the primary or secondary payer, but this can quickly get confusing, because it varies depending on the patient and the other form of insurance that they have. Consider the following situations:
a) If the patient is 65 or older and has an employer-sponsored group health plan from a large business (20+ employees), Medicare is usually the secondary payer.
b) If the patient is under 65, has a disability, and has an employer-sponsored group health plan, Medicare is usually the secondary payer.
c) If the patient has an employer-sponsored group health plan from a small business (less than 20 employees), Medicare usually pays first, unless the small business has joined with other small businesses in a multi-employer health plan, in which case Medicare is the secondary payer.
d) If the patient has Medicaid, the primary payer is Medicare.
e) If the patient has Veteran’s benefits, they must choose between Medicare and their Veteran’s benefits when seeking treatment. Only one program will pay for a single service.
f) If the patient has two or more other types of private insurance, the private carriers may have rules about the order in which Medicare and each carrier pays, so the patient’s insurance company must be contacted.
g) If the patient has COBRA continuation coverage, Medicare pays first if the patient is 65 or has a disability.. However, COBRA continuation coverage pays first if the patient qualifies for medicare based on end-stage renal disease.
h) If the patient filed a workers’ compensation claim, Medicare pays first.
Clearly, when patients have another type of health insurance in addition to Medicare, the order in which each insurance provider pays can quickly get confusing — and the situation will only get more complicated as the Medicare-eligible population in the United States increases. In order to avoid making mistakes that cause payment delays, you may want to consider outsourcing your medical billing to the experts at AnnexMed. We can help streamline your medical billing to keep your revenue cycle running smoothly. Contact us today for more information about our services!
- Posted by admin
- On January 9, 2018
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