Coordination of Benefits and Secondary Billing: Getting the Order Right the First Time

Insurance information should be verified at every visit, or at least regularly, because coverage changes. A new job, a marriage, or a retirement can alter which plan is primary. Eligibility checks sometimes reveal other coverage on file, and staff should follow up when they do.

Submitting the Secondary Claim

After the primary payer processes the claim, the secondary claim can be sent with information about what the primary paid or denied. Many practices submit secondary claims electronically with the primary payer's adjustment details included, while some arrangements, such as certain Medicare crossover agreements, forward claims automatically.

Several details need care:

• The amounts on the secondary claim must match the primary remittance
• Adjustment codes from the primary should be carried over correctly
• Timely filing limits for secondary claims may begin from the primary payer's processing date, depending on the plan
• Some secondary plans require a paper copy of the explanation of benefits

Posting the primary payment accurately is the foundation. An error in what the primary paid or adjusted leads to a flawed secondary claim.

Why Secondary Payments Sometimes Fall Short

Secondary plans use different methods to calculate payment. Some pay up to what they would have paid as the primary payer, and others may pay only the difference between their allowed amount and what the primary already paid. In certain cases, the secondary payment is zero because the primary payment already met or exceeded the secondary plan's allowed amount.

Practices should not automatically bill patients for the remaining balance after a secondary payment. Contract terms, adjustments, and patient responsibility rules determine what can be collected. Reading the secondary remittance carefully avoids both over-collection and missed collection.

Dealing With Denials Related to Other Insurance

Payers sometimes deny claims because their records show another plan as primary. This usually comes from a questionnaire the patient never completed or outdated information. The usual fix involves the patient contacting the plan to update the record, after which the claim can be resubmitted.

Billing staff can help by explaining clearly to patients what is needed and why. A short script with the plan's phone number and the exact information to provide makes the call easier. Following up in a few days helps ensure the update actually happened.