- A—The commercial insurance coverage is primary in this situation. Medicare should be billed secondarily because it will not become primary until after the first 30 months of ESRD Medicare entitlement. After that, Medicare will be primary no matter the patient’s employment status.
- C—Unless the patient has a qualifying condition, such as ESRD, the commercial insurance carrier would be primary if this is a general healthcare plan with at least 20 employees. It is important for the practice staff to verify benefits with the carrier.
- C—The staff should always verify if a patient has multiple insurance coverage, especially if the practice does not accept Medicaid. If the patient is treated in the practice, they must understand that you don’t accept Medicaid and must agree to pay any unpaid balance that is from the co-pay, co-insurance or deductible. If this is not done, then the practice is not allowed to balance bill the patient. Related note: A healthcare provider is required to let patients know when Medicaid doesn’t cover a service and confirm they agree to pay the charges in writing before providing a service.
- D—The person who is obtaining the insurance verification must ask the carrier who is primary for the patient’s coverage. Some carriers go by the birthday rule, that is, whoever’s birthday comes first on the calendar would be primary. Other carriers sometimes go by the hire date for a married couple, that is, whoever was hired first by the company would be the primary insurance carrier.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.