Navigating the Labyrinth: A Definitive Guide to Billing Secondary Insurance

So, you’re staring down the barrel of secondary insurance billing? Fear not, fellow healthcare professional! While it might seem like a trek through a bureaucratic jungle, understanding the process is paramount to getting your claims paid accurately and promptly.

In essence, to bill secondary insurance, you must first bill the primary insurance payer. Once you receive the Explanation of Benefits (EOB) from the primary payer, you use that information to submit a claim to the secondary insurer. This includes providing the secondary payer with details about the primary payer’s payment (or denial), the dates of service, the services rendered, and the patient’s identifying information. Accurate and complete information is key to avoiding claim rejections and maximizing reimbursement. Now, let’s dive into the nitty-gritty details.

Understanding the Hierarchy: Primary vs. Secondary Insurance

Before we delve deeper into the billing process, let’s clarify the roles of primary and secondary insurance. The primary insurance is the policy that pays first. This is usually determined by factors like employment, age, or court orders. The secondary insurance is the policy that picks up the remaining balance (or a portion thereof) after the primary insurance has processed the claim. Understanding this order is the cornerstone of successful secondary billing.

Determining Primary Insurance

How do you figure out which insurance is primary? Several rules, mandated by the National Association of Insurance Commissioners (NAIC), dictate this order. These rules, often referred to as coordination of benefits (COB) guidelines, consider various scenarios:

• Employer-Sponsored Plans: Generally, if a patient has coverage through their own employer and as a dependent under their spouse’s employer-sponsored plan, their own employer’s plan is primary.
• Birthday Rule: For dependents covered under both parents’ plans, the plan of the parent whose birthday falls earlier in the calendar year is primary. (Note: the year of birth is irrelevant).
• Divorce Decrees: Court orders often specify which parent is responsible for providing insurance coverage, and this dictates the primary insurance.
• Medicare and Employer-Sponsored Plans: If a patient is eligible for Medicare but is still actively employed and covered by an employer-sponsored plan with 20 or more employees, the employer’s plan is primary. Otherwise, Medicare is primary.

Documenting these rules and verifying coverage with both insurers at the outset is essential for accurate billing and preventing claim denials.

The Step-by-Step Billing Process

Billing secondary insurance involves a specific sequence of actions. Here’s a detailed breakdown:

1. Bill the Primary Insurance: This is the crucial first step. Submit your claim to the primary insurer just as you would for any standard claim, ensuring all required information is accurate and complete.
2. Receive the Explanation of Benefits (EOB): The EOB is your treasure map! It details how the primary insurance processed the claim, including the amount paid, any deductibles or co-pays applied, and any reasons for denial.
3. Prepare the Secondary Claim: Now, assemble the claim for the secondary insurer. This includes:
   • A completed claim form (often a CMS-1500).
   • A copy of the primary insurer’s EOB. This is essential!
   • All necessary documentation, such as the patient’s demographics, diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), and dates of service.
4. Submit the Secondary Claim: Send the prepared claim to the secondary insurer according to their preferred method (electronic or paper). Ensure you adhere to their specific submission guidelines to avoid rejections.
5. Track and Follow Up: Monitor the status of your claim with the secondary insurer. If you haven’t received payment within a reasonable timeframe (typically 30-45 days), contact them to inquire about its status.

Common Mistakes to Avoid

Billing secondary insurance can be tricky, and mistakes can lead to claim denials and payment delays. Here are some common pitfalls to watch out for:

• Omitting the Primary EOB: This is a cardinal sin in secondary billing. The secondary insurer needs to see how the primary insurance processed the claim.
• Incorrect Patient Information: Ensure the patient’s name, date of birth, insurance ID, and other demographic information are accurate on both the primary and secondary claims.
• Incorrect CPT/HCPCS and ICD-10 Codes: Double-check that you are using the correct codes for the services rendered and the diagnoses treated.
• Missing Coordination of Benefits Information: The secondary claim needs to indicate that the patient has primary insurance and provide details about that insurance (payer name, policy number, etc.).
• Failing to Follow Up: Don’t assume the secondary insurer will automatically process your claim correctly. Track your claims and follow up promptly on any outstanding balances.

Frequently Asked Questions (FAQs)

1. What if the primary insurance denies the claim?

If the primary insurance denies the claim, you still submit the claim to the secondary insurance, including the primary insurer’s EOB that details the reason for the denial. The secondary insurer will then determine if they will cover the service.

2. Does the patient need to meet a deductible with both the primary and secondary insurance?

Yes, typically, the patient may need to meet a deductible with both insurers. However, the secondary insurance may cover some or all of the remaining balance after the primary insurer has paid and the patient has met their primary deductible and co-insurance obligations.

3. What is “crossover” billing?

Crossover billing is when the primary insurance automatically forwards the claim information to the secondary insurance. This typically occurs with Medicare as the primary payer, crossing over to a supplemental insurance plan.

4. How do I find out the secondary insurance payer ID?

You can usually find the payer ID on the patient’s insurance card, or by contacting the insurance company directly. Many online resources also provide payer ID information.

5. What if the primary insurance paid more than the secondary insurance allows?

In this rare scenario, the provider may need to reimburse the primary insurance payer. The secondary insurer is only responsible for covering the remaining patient responsibility according to their allowed amount.

6. What if the patient has three insurance plans?

In cases of tertiary insurance, the same process applies. You bill the primary, then the secondary, and finally the tertiary, each time providing the previous payer’s EOB.

7. What happens if the patient doesn’t provide information about their secondary insurance upfront?

You should always attempt to collect information about all insurance plans at the time of service. If you discover a secondary plan later, you can resubmit the claim to the primary insurance (if within their timely filing limit) and then bill the secondary insurance.

8. How long do I have to bill secondary insurance?

Timely filing deadlines vary by insurer. You should check with each insurance plan to determine their specific requirements for submitting secondary claims.

9. Is it possible for the secondary insurance to deny a claim even after the primary has paid?

Yes. The secondary insurance may deny a claim if the service isn’t covered under their plan, if the patient isn’t eligible, or if the claim is submitted incorrectly.

10. What if the secondary insurance requires authorization?

If the secondary insurance requires authorization for a particular service, you must obtain the authorization before providing the service, even if the primary insurance doesn’t require it.

11. Where can I find information about state-specific coordination of benefits rules?

Each state’s Department of Insurance will have information on state-specific regulations regarding COB.

12. What are the best practices for documenting coordination of benefits?

Document everything! Keep detailed records of all insurance information, EOBs, and communication with both insurers. Having a clear paper trail is invaluable in resolving any billing disputes.

By following these steps and understanding the intricacies of coordination of benefits, you can confidently navigate the world of secondary insurance billing and ensure that your practice receives the reimbursement it deserves. Remember, attention to detail and proactive follow-up are your greatest allies in this endeavor. Now go forth and conquer those claims!