It seems there are a lot of questions that arise about how to calculate adjustments and determine patient responsibility when there is more than one plan. This is considered Coordination of Benefits. As a medical biller today, and a claims examiner back in the 1990’s, we had to calculate coordination of benefits manually. Today, our practice management/medical billing systems do help to determine patient responsibility, but, are they often accurate if we don’t tell the system what the method of calculation is? There are currently three methods of calculating benefits when there is more than one plan in play. The method of calculation is determined by the patient’s secondary plan. It is important than when verifying benefits with a patient’s primary plan, that we verify benefits and eligibility with the patient’s SECONDARY plan as well.
In my search for something to help medical billers with the calculations after a secondary payment, I found that MOST courses, text books and other resources found, focused on the determination of the primary payer, rather than how payments were calculated after both plans have paid. It’s been my experience in almost 25 years, that 99% of the time the primary payer has already been determined by a patient’s primary plan. I do think it’s important to understand how a plan is considered primary, most times the primary payer has already been established. That leaves medical billers with the unanswered questions about what a patient owes, and what amount is considered “adjustable”. Ultimately, these questions affect the bottom line of the practice. How a patient’s secondary plan coordinates benefits becomes extremely important. Some plans do not have coordination of benefits, which can mean that a secondary may not pay anything depending on their normal benefit payment had no other carrier been involved. If a primary payment is equal to or more than what that secondary would allow, no benefits can be payable.
PMRNC has updated our learning center to contain a whole section of calculating benefits with dual coverage. We even have samples for every method a secondary would use. PMRNC members should login and visit the Learning Center, then click on “Coordination of Benefits”. We are currently working on a worksheet which medical billers can download and use when calculating dual coverage payments and adjustments, to help you determine a patient’s responsibility. If you are a medical biller who has taken a course, class, and learned these calculations, please let us know in the comments area! We were unable to find resources that helped medical billers calculate benefits with dual coverage.