Thursday Troubleshooter: Primary vs. secondary insurance

Apr 4th, 2013
Troubleshooter 4 4

This week's Troubleshooter question was addressed by Roy Shelburne, DDS, of Jonesville, VA, and a member of Speaking Consulting Network. His replies are shown in bold face type.

QUESTION: My dentist is a preferred provider for my primary insurance but not my secondary. When coordinating my benefits, the primary first pays for the services in full at the agreed network fee. Can my dentist then send it to my secondary to have them pay for the difference in the office's normal fee and the in-network primary fee, or are they supposed to write off the amount above the primary's agreed fee and nothing gets billed to secondary? The dentist may send the secondary claim to the secondary carrier.




Example: The normal office fee is $200. Primary pays 100% of filed fee of $150. This is the patient's maximum responsibility; however, if paid more, the doctor may keep up to the full fee of $200 after both have paid.Normally the dentist writes off the $50 difference if he/she is in the primary network, but since there is a secondary insurance, a claim is automatically generated and sent to the secondary for the remaining $50. The secondary pays $50 so the dentist gets full fee paid, even though the dentist is in network with one of them.

What if it's for something that my secondary wouldn't pay 100% for treatment? Example: The normal office fee is $200. Primary pays 100% of filed fee of $150. Normally the dentist would write off the $50 difference if he/she is in the primary network, but since there is a secondary insurance, a claim was automatically generated and sent to the secondary for the remaining $50 unpaid. Secondary has nonduplication clause and pays at 50%, so it pays $25 to the dentist (50% of remaining unpaid $50 from primary). Does the dentist then write off the remaining unpaid $25? Yes, you understand correctly. The dentist will need to write off any amount that remains unpaid by primary and secondary that is over the contracted patient responsibility... in this case, $150. It is the very rare case where primary and secondary pay more than the full fee (here that full fee is $200). If the combined payments are more than $200, the amount over $200 should be returned to the secondary carrier. (The patient should not benefit from having the dental work completed.) I hope this helps.

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Send your questions to megk@pennwell.com. All inquiries will be answered anonymously every Thursday here on DIQ.


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