Insurance Adjustments

Billed amount is $150.00. Primary allows $150, adjusts off $15 leaving patient with a $135 co-pay. Secondary insurance pays $81 and says adjustment is $42 leaving the patient with a $27 co-pay. Which adjustment do I post? Is it always the primary insurance adjustment? Any help would be appreciated. I'm new to secondary billing and can't find this answer anywhere!

re: Insurance Adjustments

First question would be, did the 2ndary process as primary or the 2ndry carrier?
By what is written, I am thinking the 2ndry processed as a primary.

re: Insurance Adjustments

I'm assuming they processed as 2nd. They won't even accept the claim without the primary payment information. We are out of network with the primary and they always put the whole amount as co-pay. Secondary (whom we are in network with) always pays according to their fee schedule after the primary has processed the claim.

re: Insurance Adjustments

Personally, I would call and verify how they processed. If they did process as 2ndry, then I would go by the 2ndry's polices/payments.

re: Insurance Adjustments

Thank you for your help

re: Insurance Adjustments

But the secondary insurance may not realize there is a primary carrier, therefore they (secondary) would pay as primary. You may want to call the secondary and see what they have on file, whether or not they are pri or sec. It sounds as if the secondary paid as primary. Also, if you are not in network with the primary and they allowed $150, then that is what the patient should owe, there shouldn't be a $15 adj.

re: Insurance Adjustments

We don't do insurance adjustments from insurances we don't par with. In this case it sounds like the primary ins is the pt's and the secondary could be from spouse maybe. If you par with the secondary ins, than you would do their adjustment and the balance after any payment would be the pt's responsibility.

re: Insurance Adjustments

Different scenario: If we participate with both primary and secondary, which adjustment would I post? Primary only?

re: Insurance Adjustments

You would only post the primary adjustment in that case.

re: Insurance Adjustments

You can post both adjustments as long as you are not billing the pt more than the insurance says you can for pt responsibility. Obviously you would bill them the lowest amount of the two.

re: Insurance Adjustments

Thank you so much for your help.