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Medicare, Medicaid, Life and Health Insurance/dual health coverage contractual adjustments


QUESTION: Our hospital has had problems billing correctly for my husbands services.  The claim in question had a higher contractual adjustment with his secondary coverage which should have resulted in no copay. However, they are only allowing the adjustment on the primary policy.  Had they used only the adjustment on the secondary policy (ignoring the primary policy's adjustment) we have a zero balance after both insurance payments. They are unable to grasp this, and have since sent us to collections (after 18 months trying to communicate with them.)  Suggestions?

ANSWER: Hi Connie -- Just got your question - problem with site.

Hospitals must bill primary insurance first then send the balance to the secondary carrier.  Depending on your coverage you may have a small copay.  

No secondary carrier can be billed prior to the primary.  Just does not work that way.  However make sure that your primary paid properly and your secondary carrier was billed the proper amount.

Good Luck!

---------- FOLLOW-UP ----------

QUESTION: Both primary and secondary insurances were billed in the correct order.  The problem is, they will  not honor the difference in contractual adjustments.  Our secondary insurance  had a lower allowable charge in their agreement with the provider.  They are requiring we pay the allowable charge of the primary insurance, which is higher.  Thank you for your time.

Primary carrier sort of "makes the ruling" when they are billed first.  Secondary coverage only has to pay according to your contract on the balance after the primary deemed the charge.
So the allowable was already deemed by your primary.  

If your primary carrier let's say did not pay and denied the entire charge or perhaps had applied it to your deductible then your secondary would maybe pay according to their allowable.

It is all a game and unforunately most of the time the patient loses.

However since your account is in collections remember you can usually negotiate the balance......usually after a year you can get them down to 50%.  

Medicare, Medicaid, Life and Health Insurance

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Has your medical insurance company denied your claim and refuses to pay? Have you received a pre-authorization and still your insurance company refuses to pay? How can you get your insurance company to reverse a denied claim? How do you get a provider to waive your copayment if you are financially unable to pay? Can a provider sue you for a unpaid bill and will they? Can a provider send me to a collection agency for a medical bill? If my insurance company does not pay, am I responsible? If you have these questions or others on why your insurance company is not paying your bills, I can help. I can give you "tricks of the trade" to get your insurance company to pay. I have limited knowledge on Medicare and Medicaid and that is not my expertise. Each state is very different regarding Medicare and Medicaid so you need to review their website when you have questions. So please no Medicare or Medicaid questions!!


In the medical field for over 20 years spending majority of time in the collections aspect.

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