Secondary Insurance Billing Explanation
- Most insurance carriers will not insure a person who already has a similar level of coverage through another carrier. However, it is possible to have duplicate policies provided that there is a clear contractual relationship between the two as to which is primary and which is secondary. For example, a person who has insurance through an employer, but is also covered under a spouse's policy, usually has his own coverage be primary and the spouse's coverage be secondary; this provision will be written into both contracts.
- In some situations, another policy might serve as a primary insurance. For example, in many states, the state's worker's compensation program covers on-the-job injuries as a primary payer. Also, in many states, an automobile policy pays some or all of the medical expenses associated with a vehicle accident, before the person's health insurance policy is liable.
Coordination of Benefits
- The final responsibility for determining the proper charges that flow to primary and secondary (or even tertiary) payers is the health-care provider. Hospitals have insurance-verification departments that work with all applicable insurance carriers to determine which policies are primary, which charges allocate to which payer, and the total amount of liability due directly to the patient. This effort is called "coordination of benefits."
Medicare Secondary Payer
- Many senior citizens have Medicare plus a supplemental insurance policy--either one that they purchase as an individual, or one that they get as part of a retirement or pension plan. Medicare requires payers to complete a "Medicare Secondary Payer Questionnaire" that determines whether Medicare is primary or secondary, depending on a range of questions including patient age and history as a railroad worker.
- For more complicated issues, like elective surgeries that are not medically necessary (including most types of plastic surgery), a patient might have to work with all applicable insurance companies before working with a health-care provider, in order to determine which payer will certify the service and agree to accept primary responsibility for the claim. In those situations, the patient should call the customer-support hotline for each payer, outline the situation and coordinate benefits directly.