Don’t leave money on the table when the patient is covered by two insurance plans. Consider the situation where the primary insurance reimbursement rate is 75% and the secondary insurance reimbursement rate is 90%. If you do not pursue the secondary insurance payment, you will be leaving at least 15% of billed charges uncollected. Many of these claims slip through the system when the primary insurance pays and there is no patient responsibility. We simply post the primary insurance payment and apply a contractual adjustment to the balance. Watch for those claims with a secondary insurance when you work your assigned accounts. You may want to run a unique report that will capture only those accounts with a secondary insurance.
Most, if not all payors, now follow the Preservation Coordination of Benefits (COB) claim adjudication as adopted by the National Association of Insurance Commissioners (NAIC). “Under preservation COB, a secondary plan “preserves” its own deductibles, co-insurance and exclusions. It usually does this by determining its liability on a claim by claim basis. The secondary plan simply calculates how much it would have paid had it been primary, subtracts whatever the primary plan paid and pays whatever balance (if any) results as its secondary liability.” This statement is taken from the NAIC COB Guide published by Thompson Publishing Group, Inc. You will find similar language in your managed care contracts and/or provider manuals. (Please note CMS follows a different set of reimbursement calculations when Medicare is the secondary payor.)
In some instances, the patient may have a greater liability when the secondary payor adjudicates a claim. This can happen due to unmet secondary insurance deductible, co-insurance/co-pay amounts or other circumstances. The provider is typically obligated by contract to bill the patient the liability amount determined by the secondary payor, assuming the claim was adjudicated properly.