Double Insurance Coverage- Provider Billing Fraudulently?

Discussion in 'Health Insurance and Ancillary Benefits' started by cruiserandmax, May 23, 2017.

  1. cruiserandmax
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    cruiserandmax New Member

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    My husband has individual health insurance through his job (his primary insurance). He also has a separate health insurance plan (from a different provider) that we pay for through my job. This is a result of us not getting around to canceling him from the secondary plan after he got his job.

    Generally he has been providing his primary insurance to providers. They generally cover most of the cost but there is always a "co-insurance" amount listed in the EOB that the provider ends up billing us for. We pay it- then we submit a claim directly to his secondary insurance who then pays us that full "co-insurance" amount.

    Recently we thought it might be easier to just give the healthcare provider information from both insurance plans and let them do all the billing. On a recent urgent care visit this resulted in the urgent care clinic billing BOTH providers for the full visit amount ($438). Both providers payed a negotiated discounted rate and had a leftover "co-insurance/patient responsibility" amount. The provider then billed us for the lesser of those two amounts ($48).

    I am nearly 100% confident that had we just provided the primary insurance coverage (which had the $48 leftover 'co-insurance' amount) and then sent a claim in ourselves to the secondary insurance for that $48 they would have reimbursed us the $48 (that is how we had been doing it before this case).

    My question- Is is appropriate for the clinic to be billing both insurance companies for the same amount/service, and accepting a negotiated payment from each of them without the other knowing? And further billing us for one of the remainders?

    In this case they billed $438 to both providers. From the primary insurance they accepted an adjusted amount of $188 for which the insurance payed $140. From the secondary insurance they then accepted an adjusted amount of $120 with an amount of $65 as "not covered" as indicated by the secondary insurance EOB. They are now billing us for $48 (seemingly the amount listed on the primary EOB as co-insurance).

    Sorry if this is totally confusing (it is for me too!).
     
  2. somarco
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    somarco Well-Known Member

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    COB (coordination of benefits) generally works like this.

    Primary carrier pays according to contract. Secondary carrier reviews the claim, if primary paid more than the secondary would have paid if primary, secondary pays nothing. If primary paid less than secondary would have paid if primary, secondary pays difference in what they would have paid and what primary paid.

    Example.

    Provider submits $500 claim to primary. Primary carrier reprices to $300 and pays 80% or $240. Secondary also gets $500 claim, would have paid $230, they pay nothing.

    Doubling up on coverage is rarely worth the premium you paid for the secondary insurance.
     
  3. LostDollar
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    LostDollar Well-Known Member

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    10-15 years ago, with full family medical needs AND more liberal employer payments towards employee insurance, we had primary and secondary insurance for a year or two. The payment process worked as OP states in her example. In that set of circumstances most of our bills were paid 100% by insurance and the insurance costs were worthwhile.

    As insurance costs have increased and employers have expected employees to pay more, I could never again justify carrying two sets of coverage, even assuming COB as cited by OP. Taking COB as cited by somarco, I think it would be extremely difficult to justify two policies.

    If there was a level of medical expense that would justify that, I would think there would be a possibility that the employer carrying the secondary coverage would be looking at a review of, and change in, their plan admission policies.
     
  4. cruiserandmax
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    cruiserandmax New Member

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    Thanks for the replies!

    We are definitely planning to get rid of the secondary plan during my next open enrollment period (we unwittingly waited past the 30 days to cancel after he got his new primary plan from his new job). I just wanted to make sure we are getting whatever value we can out of the dual plans while we have them.
     

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