Insurance billing can be complicated enough when only one payer is involved, but sometimes patients have more than one healthcare plan. When would a biller submit to secondary insurance? If a patient is covered by two policies and there’s still a balance after the primary policy has been paid, you’ll need to submit another claim to the second payer.
When Would a Biller Submit to Secondary Insurance?
There are several situations in which a patient is covered by two different insurance policies. For example, someone who’s older than 65 and still working could be covered by both Medicare and their employer’s plan. Sometimes spouses will enroll in both their own and each other’s employer policies. Younger adults who are under 26 and have employer coverage might also be on a parent’s plan. Regardless of the reason for having more than one health insurance plan, one plan will always be the primary policy and the other will be the secondary insurance policy. If the primary insurer has paid their portion of the bill and there’s still a balance, you should submit the claim to the secondary insurance company before billing the patient.
If a patient has more than one insurance plan, it’s important to confirm which one is their primary coverage before submitting a claim. Healthcare practices cannot submit a claim to both insurance companies at the same time. Instead, you’ll need to submit to the primary insurance, wait to see how much the primary insurance will pay, and then submit to secondary insurance.
To figure out which is the primary insurance, you’ll need to check the coordination of benefits (COB). This is a provision in an insurance policy that specifies what each insurer is responsible for paying for. While there are a number of rules and variables that can affect which insurer is the primary payer, there are some general standards to know. Usually, a patient’s coverage from their own employer will be primary insurance and their coverage from a spouse or parent would be secondary insurance. If a patient has both Medicare and employer coverage, the employer-based insurance pays first as long as the company has 20 or more employees. If it’s a smaller business, Medicare pays first.
It’s important to confirm the COB before submitting a secondary insurance claim. Claims that are submitted in the wrong order are more likely to be denied, which causes delays and additional follow-up work for your billing team.
How to Submit a Claim to Secondary Insurance
After you’ve billed the primary payer, submitting a claim to secondary insurance mostly works the same way as any other claim. In addition to regular billing details, you’ll also need to include the total that was billed initially, how much the primary insurer paid, and why the primary insurer didn’t pay the full balance. It’s also a good idea to include the full explanation of benefits from the primary insurer.
Once you have the claim prepared, there are two ways to submit it to secondary insurance.
Submit Directly
Many payers, especially larger ones like Medicare and major private insurance companies, allow providers to submit claims directly. These days, you’ll almost always be submitting claims electronically. Going directly to the payer means you don’t need to worry about the cost of an additional service, and you’ll deal with the insurer without a middleman. However, you’re also responsible for catching all of your own errors. Billing a secondary payer can be complex, and it’s easy to make a typo or leave out a piece of information that could cause the claim to be denied.
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Submit Through a Claims Clearinghouse
When you use a claims clearinghouse, you’ll submit your claim file to your clearinghouse account instead of directly to the payer. The clearinghouse will review the claim and check it for errors. If there’s an issue, the system will let you know so you can fix it before resubmitting. If everything looks good, the clearinghouse will submit the claim to the payer. Since you use the same clearinghouse account for every payer you bill, you should already have the claim information from the primary insurance claim, along with the explanation of benefits and amount paid, in that system. This makes it easy to access the details you need to bill secondary insurance. You also won’t need to reenter information about the appointment you’re billing for in a different payer’s claims system.
Using a claims clearinghouse might feel like adding an additional step, but unless you’re only dealing with a very low volume of claims, it can save time and streamline your process. Catching errors and omissions before you submit a claim saves you the time you’d otherwise spend appealing a denied claim. This can be especially helpful with secondary claims since they require some extra information. For example, if you tried to submit to secondary insurance without adding the amount the primary insurance paid, the clearinghouse would flag that omission before sending in the claim.
How Apex EDI Simplifies Secondary Insurance Billing
Apex EDI is a flexible and easy-to-use clearinghouse. Our scrubbing feature catches errors in your secondary insurance claims before you send them along to the payer so you can correct the problem immediately and avoid a frustrating denial. This system means 95% of claims submitted through Apex EDI are approved, and most of our providers are paid about 12 days faster than they would be otherwise. We designed the program to be intuitive for providers, so you’ll be able to easily access the information from the primary insurance claim instead of starting from scratch. Apex EDI works seamlessly with whatever electronic health records and practice management tools you’re already using, and we can customize our solutions for any type of healthcare practice. You’ll also receive unlimited support, so if you’re dealing with a tricky secondary insurance situation, we’re here to help.
The best way to find out if a new system will work for your practice is to see it in action. Schedule a demo of Apex EDI today!
