Health insurance hunter: secondary claims

I work for a small nonprofit organization in Hawaii, and it was eye-opening to enter the mysterious world of health insurance coding and billing. I gained a new appreciation for my doctor (aka primary care physician), my son’s pediatrician, my dentist, and my optometrist.

Earlier this year, I shared some stories about the sometimes confusing and frustrating health insurance claims process. But it doesn’t end there.

Some people have multiple health insurance policies. These secondary claims are tricky. The secondary plans often, but not always, pay the copayment or coinsurance (aka the “patient’s responsibility”). The secondary plans sometimes, but not always, pay for services that the primary plan does not cover.

Healthcare providers have to verify which insurance is primary. We have to verify which claims are forwarded (“crossover”) automatically, and which must be submitted manually. Sometimes we have to identify that there is a secondary plan, to avoid duplicate billing.

Some days I have to be a health insurance hunter, and other days I have to be a secondary claims health insurance hunter. Here are a few stories…

Why is there a payment and denial? The best insurance plans are the ones that automatically forward claims to the secondary plan – and let you know it upfront. We submitted a claim to Payer A1, and received a payment. Then we submitted a secondary claim to PayerA2, and received a payment – as well as a denial notice. Why? Because we sent a duplicate claim. That’s when we found out that Payer A1 automatically forwards claims to Payer A2.

The two copayments. We submitted a claim to Payer B1, and received a payment, along with a notice that the client had a copayment. The client paid the copayment. Then we received a payment from Payer B2. We didn’t know that the client had a secondary plan and we didn’t know that Payer B1 automatically forwarded claims to Payer B2. We refunded the client, with our apologies.

Why did they pay? We submitted a secondary claim to Payer C2, and received more than we expected. We immediately called Payer C2 to let them know about the overpayment, and set the check aside. Three months later, we received a letter saying that an “audit” uncovered the overpayment. Payer C2 demanded repayment – even though we never deposited the check – and threatened to deduct the amount from future payments, without apologizing for their mistake.

Why didn’t they pay? We submitted a claim to Payer D1, and received a payment, along with a notice that the client had a copayment. We submitted a secondary claim to Payer D2 for the copayment, but received a denial letter. Their explanation: the amount Payer D1 paid was more than the amount Payer D2 would have paid as the primary plan (even though Payer D2 is not the primary plan).

Are you satisfied with your health insurance plan(s)? Are your health care premiums affordable? What about your copayments or coinsurance?

 

Artwork courtesy of All-Free-Download.com.

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Tags: Health Insurance, Health Insurance Claims, Secondary Claims

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