Working with primary and secondary insurers
2 January 2006
If a physician is contracted with both the primary and secondary insurers for a patient, the following process can be followed:
After filing a claim with the primary insurance company, the billing office should submit a claim to the secondary insurer for the patient-responsibility portion of the charges.
In many instances, the secondary payer's explanation of benefits (EOB) will show a zero payment to the physician, with a zero patient responsibility. And, according to the secondary EOB, the physician cannot collect from the patient what the primary payer's EOB shows as the patient's responsibility.
If a physician is NOT contracted with the secondary payer, he or she can bill the patient for the amount left unpaid by the insurance carriers because he or she has not agreed to the secondary payer's fee schedule. If a physician IS contracted and bound by both primary and secondary contract agreements, he or she must write off the patient's portion of the bill.
To forego collection of a co-payment or deductible does not violate the statutory prohibition against routine waiver of co-pays and deductibles because:
- You aren't waiving the co-pay, deductible or coinsurance as a marketing ply or other inducement to increase business;
- You aren't causing an insurer to pay more than is due under its policy with your patient;
- When you submit the claim, you place the amount you usually charge in the appropriate field; and
- Since you are contractually bound by the secondary payer's hold harmless clause, your waiver is not routine but an intended result of the insurance code's hold harmless mandate. You've simply agreed to a fee schedule with the secondary insurer that happens to be less than the primary insurer's allowable.