02/22/2019

Credentialed With Medicare Only-Seeing Patients With Other Secondary Insurance

We are currently accepting Medicare and we are working to get on the rest of the insurances. When Medicare patient call our office to make an appointment and we inform them that we take Medicare. Do we need to ask them another question before making the appointment "do you have secondary insurance"? If they do have secondary insurance which will be out of network for me, do we need to let them know we will bill secondary insurance out of network? Or Do we just bill Medicare only and inform the patient that they will have to pay 20% coinsurance since we don't accept secondary insurance? How does this work?

When gathering the patient’s insurance information, it is good to obtain their secondary insurance as well, this way you have it on file for when you become credentialed.  When an insurance is a secondary payer, the rules regarding networks do not always apply. 

• Many times, a patient will have a Medicare supplement plan, where as long as the provider accepts Medicare, the remaining co-insurance or deductible would be covered per the patient’s plan benefits (some supplement plans do not cover the part B deductible, and may apply some or all of the co-insurance to a secondary plan co-pay)
• The same logic would apply if the patient had military coverage secondary to Medicare under CHAMPVA or Tricare for Life

Network rules would still apply in two specific circumstances:

• If the patient has Medicaid or a Medicaid Managed Care plan secondary to Medicare, the balance may be denied if the provider is out of network- in this case, any outstanding co-insurance or deductible from Medicare would have to be written off since the patient cannot be held liable for the balance

• If the patient has a commercial policy through their employer, network rules would apply- depending on the patient’s benefits when Medicare is primary, they may cover the balance from Medicare or apply it to patient responsibility