Secondary Claims Processing at Your Fingertips

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Claim Processing

Secondary billing is exactly as the name suggests, the process of billing a second policy or payer once the primary claim has been processed and the reimbursement posted. Of course, in actuality, it’s not so simple. Not only must you determine which policy is the primary and which is secondary, you must understand the different kinds of coverage, when to use each and how to file a secondary claim. Plus, this doesn’t include possibly explaining all of this to a patient. 

Well, take a breath. We’re going to sort it all out and simplify secondary claim processing and show you just how easy it can be with software like Apex EDI.

Determining Primary and Secondary Insurance Policies

Start by figuring out which policy to bill first. This is usually a simple process as the only other policies a patient may have are say dental or vision on top of their standard medical insurance. Common types of secondary insurance include:

  • Vision
  • Dental
  • Hospital Stay
  • Long-Term Disability
  • Life
  • Accident 

Depending on the services you provide, determining which policy to bill can become more granular. This determination process by payers, which is called coordination of benefits (COB) includes pages and pages of rules to help billers position policies on the hierarchy. Even then, determining COB is very situational, and often more of an art than a science. 

In short, payers determine filing orders by consulting a list of industry standards and CMS regulations. Of course, these too are always being updated and are constantly changing. So, here’s what you need to know: coordination of benefits must occur before billing, otherwise you will risk delaying the reimbursement cycle with denials, and thus aging (essentially decreasing the value of) your receivables from payers. 

An Example: The Birthday Rule

Here’s an example of just one of many COB rules. When treating a child patient who is covered by plans of two natural parents, you can use the birthday rule to determine which to bill. The parent who has the first birthday in a calendar year is the policy which will be billed first. It’s important to remember, however, that you are not billing the policy of the parent that is older. For example, the father may have been born on May 1st, 1980, but because the mother was born January 12th, 1982, her policy would be billed as the primary. 

Working with the Patient

What’s important to remember, when it comes to working with your patients, is that coordination of benefits is not their choice. COB is determined by those rules and regulations and is a decision for the insurance companies. As with all insurance and billing, providers must keep in constant communication with their patients before, after, and throughout treatment to manage expectations when it comes to multiple insurance policies. 

A patient may believe that they can choose the policy with a lower copayment or deductible, and could be frustrated when that is not the case. To ensure a pain-free payment experience for both patient and billing staff, it’s important to clearly communicate what they can expect and to break it down into layman’s terms. 

In some cases, a patient may not know which is their primary insurance policy and look to you for guidance. Do not make assumptions or try and guess which to bill first. A little more research now will save you a lot of heartache with denials later on. In this case, you can: 

  • Consult tools or subscription services like Availity which lay out COB rules for you
  • Encourage your patient to call their insurance providers for COB
  • Direct your patient to a member-specific form or portal on the payer’s website to submit COB (process takes typically 10 days)

Working with Payers

Regardless, insurance companies are going to want to speak to patients directly. Empowering patients with helpful resources that include phone numbers and payer website information can help relieve the burden from billing team and encourage patients to take control of their treatment and coverage. 

From here, you should be able to make a quick call to the insurance company’s customer service to confirm that COB was done (if not, you’ll need to go back to the patient, rinse, and repeat). This is the same step you would take if, for one reason or another, both payers insist they are not the primary policy. 

Denial Management for Secondary Claims

If a claim was denied because COB was not done or not updated, it’s no surprise. Especially if you’ve encountered a scenario like above where a patient had to make a call. This is not uncommon considering large insurance companies often have separate COB departments and information may not get all the way across. You may need to call, inform them the COB has been updated, and ask for the claim to be reprocessed. It’s a good process to set reminders and follow up on these claims regardless. 

Streamlining Secondary Claims with Apex EDI

So, as you already know, secondary claims can be pretty complicated. Luckily, Apex EDI’s clearinghouse software takes the hassle out of claim processing. Secondary claims are automatically drafted from EOBs and only take a single click to submit. The result? A quicker reimbursement cycle and a more relaxed billing staff. Schedule a demo today to see just how easy secondary claim processing can be.

Already an Apex customer? Activate secondary claims processing in your account. Check out the How-To Guide

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