Are Providers Required to Bill Secondary Insurance?

When multiple health insurance policies are involved, understanding how they interact to cover medical expenses is important. This article explains the billing procedures for secondary coverage.

Understanding Secondary Coverage

Secondary health insurance provides additional coverage beyond what a primary health insurance plan covers. When an individual has two or more health insurance plans, a process known as Coordination of Benefits (COB) determines the order in which these plans pay for medical services. COB rules ensure that the total benefits paid by all insurers do not exceed the total cost of the medical services, preventing overpayment or duplicate payments.

The primary plan is always responsible for processing the claim first and paying its share of the coverage amount. After the primary insurer processes the claim, any remaining eligible expenses may then be submitted to the secondary plan. This process ensures that the insured party receives the maximum benefit from their combined coverage, helping to reduce out-of-pocket costs for deductibles, copayments, and coinsurance.

Multiple reasons can lead to an individual having secondary insurance. For instance, someone might be covered by their own employer’s policy and also under a spouse’s plan, or a child might be covered by both parents’ plans. Individuals with Medicare might also have another commercial insurance plan or a Medicare supplement plan.

Provider Billing Obligations

Healthcare providers generally bill secondary insurance, though specific requirements can stem from various sources rather than a universal legal mandate. Industry standards and contractual agreements providers hold with insurance companies often stipulate the billing of secondary coverage. These agreements are designed to streamline the claims process and ensure patients receive the full benefits of their combined policies.

The typical process involves the provider first submitting the claim to the patient’s primary insurance carrier. This initial submission includes detailed information about the services rendered. The provider’s billing department then waits for the primary insurer to process the claim and issue an Explanation of Benefits (EOB).

The EOB from the primary insurer details what was paid, any adjustments made, and the patient’s remaining responsibility. Once this EOB is received, the provider’s billing team prepares a new claim for the secondary insurance, attaching a copy of the primary EOB. This step is crucial as it informs the secondary insurer of the primary plan’s payment and any remaining balance.

Submitting claims to secondary insurance generally follows the same format as primary claims, often through electronic data interchange (EDI) for efficiency. The claim sent to the secondary insurer will include the total amount initially billed, the amount paid by the primary insurer, and the reason for any unpaid balance.

Patient Actions and Information Sharing

Patients play a significant role in ensuring their secondary insurance is billed correctly. Upon receiving healthcare services, it is important to provide the provider with accurate and complete information for both primary and secondary insurance plans. This includes policy numbers, group identification numbers, and any specific details related to Coordination of Benefits (COB). Confirming this information at each visit can prevent billing delays or errors.

If a patient believes their provider is not properly billing their secondary insurance, several steps can be taken. Initially, the patient should contact the provider’s billing department to confirm that both primary and secondary insurance information is on file and that claims have been submitted in the correct order. It is helpful to have copies of any Explanation of Benefits (EOBs) received from the primary insurer, as these documents are essential for secondary claim processing.

Patients can also directly contact their secondary insurance company to inquire about the status of claims or to understand their specific COB rules. Some secondary insurers may require the patient to provide a copy of the primary insurer’s EOB directly. In situations where a provider does not bill secondary insurance, patients typically have the option to self-submit a claim to their secondary insurer. This usually involves completing a claim form and attaching the primary EOB, along with any other required documentation.