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Coordination of Benefits

Norelie Posted Mon 09th of June, 2014 12:06:21 PM

Can someone please tell me what to do when secondary insurance pays more than the remaining balance from primary insurance. I have a few cases where secondary pays entire balance for a claim even though I sent primary insurance EOB to indicate that only the copay is the remaining balance. Do I automatically refund the secondary or wait?

SuperCoder Answered Mon 09th of June, 2014 13:43:28 PM

There are a number of factors to take into consideration when handling overpayments from secondary insurance companies. The first thing you should do is to make sure that the patient’s coordination of benefits information is correct with both insurance companies. This will help to determine if there is an actual overpayment or if the insurance company processed the payment incorrectly. If the coordination of benefits information is correct, check with the insurance company to make sure that they processed the secondary payment correctly in accordance with the primary payer’s explanation of benefits.

If the secondary payer did not process the payment correctly, have the claim reprocessed and you should refund the overpaid amount. It is much easier if you have the payer send a refund request in writing. This will ensure that the refund is applied correctly. In most situations the claim number, insured number, and the requested amount is included in the request.

If the insurance company did process the claim correctly and they inform you that there has been no overpayment made, it may be because the secondary insurance has a higher allowable than the primary insurance company. To determine this ask the secondary payer how they determined their payment and verify the allowable from both the primary and secondary explanation of benefits. If the secondary did allow more than the primary, you will need to make an adjustment to the overpaid balance to zero out the claim.

Some insurance companies have their own policies for handling overpayments. Some private insurance companies do not take into consideration the primary payment and will advise you to send the overpayment to the patient. Make sure to document well for any overpayment scenario to ensure you are covered if any questions arise in the future. Hope this helps.

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