Coding Cues: Dual insurer errors

March 21, 2008

While reviewing old accounts, we discovered numerous payment errors involving patients with primary and secondary coverage. Often, when the primary insurer issued a payment, our staff made an adjustment based on the allowed amount indicated on the EOB. Then the secondary insurer paid a portion of the write-off. The question now: Who should get the refund--the insurer or the patient?

While reviewing old accounts, we discovered numerous payment errors involving patients with primary and secondary coverage. Often, when the primary insurer issued a payment, our staff made an adjustment based on the allowed amount indicated on the EOB. Then the secondary insurer paid a portion of the write-off. The question now: Who should get the refund-the insurer or the patient?

That depends on the contractual arrangements between your practice and the insurers and on what was written off. If your practice had a contract with the primary insurer when the services were rendered, you are probably obligated to adjust the difference between the charge and the amount allowed by the insurer. If the allowed amount included a patient copay, however, the patient must pay, either out of pocket or via a payment from the secondary insurer.

If the difference between the charged and allowed amounts was written off, the second insurer overpaid and should get the refund. But if the write-off included the patient copay amount, reinstate that portion of it and post the payment.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.