Two payers and secondary payer has higher allowed amount/contracted rate than primary.

crystalp 6 years ago in Billing/Electronic Modules updated by Shauna Dall 6 years ago 8

If you have a client whose secondary payer allows more than the primary payer and the secondary processes the claim by paying whatever the CCD was from primary but still owing CCD, do you charge the client or adjust it off, since the secondary covered a minimum of the CCD from primary? Ie. primary Health Partners has a lower allowed amount for a certain code than secondary BCBS. HP has a $25 co pay. BCBS pays the co pay, sometimes more, but then is also processing the claim with CCD up to the BCBS allowed amount (which in this case is pretty decent amount). Do you charge the client the difference or adjust it off since you were paid by primary and the secondary covered the CCD from primary? Thanks. sorry it's confusing to explain this.

Crystal, can you lay it out like this - or is this what you are asking?

Total Charge $300.00

HP pd $100.00

HP adj $50.00

HP copay $25.00

HP coins $125.00

HP B6  $250.00

Total sent to BCBS

$25.00 copay

$125.00 coins

TOTAL $150.00

BCBS pd $75.00 (covers copay and part of coins)

BCBS adj $25.00

BCBS PR balance $50.00

BCBS B6 $275.00

Do you charge the client the $50.00?

Here is the service line example:

Total charge: $192.00

HP paid: $56.11

HP co pay: $25.00

HP adj: $112.48

HP tax: -1.59

BCBS 2ndary billed: co pay plus adjustments

BCBS paid: $86.36

BCBS CCD $28.89

BCBS Adj: $20.64

Do I charge the client $28.89 that BCBS is allowing even though BCBS covered the $25 co pay from HP. I was charging it because I guess I didn't really think much of it but the client recently called about it. Technically, I think we could bill the client this but I'm curious what other clinics do in cases like this.

I think it's fine to write it off since the 2ndary covered the CCD from primary. It's just that BCBS allowed amount for this particular code is much higher than HP. 

You can not charge the client. 

You cannot Charge the client.  I would definitely call BCBS again on this one, as it does not seem right that they are not just paying what was left by the Primary insurance.  They may be thinking they are paying as primary as well.  Something does not seem right about how they processed the claim.

I agree with Susan Davis and mboron, that you cannot charge the patient/client.  Also, as you may know, BCBS is in a big mess for overpaying in - I think for MA and PMAP contracts - and has recouped a lot of money because of their mistake. Accepting what appears to be an overpayment may must result in a recoupment hassle later. 


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I triple agree, you cannot charge the client in this instance.

BCBS is processing HP adjustment, plus copay, plus tax -

86.36+28.89+20.64 = 135.89 (BCBS)

25.00+112.48-1.59 = 135.89 (HP)

BCBS did not process the claim correctly.  Either you COB tab isn't going through to them correctly, or there is something preventing it from processing there or through the clearinghouse.  BCBS should only be processing the 25.00, although they can decide to pay more, they can't decide to charge the client more.