Medicare
Secondary vs. Supplemental, Who’s on First?
Lesia Crawford
CEO, GoGo Billing
877-874-4646 ext. 1
[email protected]
W
ell folks, I know you’ve all just been
waiting on the edge of you seats to learn more
about Medicare and I won’t disappoint! I will
do my best to decode the ins and outs of this
mysterious medical plan. Supplemental vs
Secondary is our topic and I’m even going to
throw a little participating vs non-participating
in the mix! Maybe even a little replacement
plan action to make sure you are paying
attention. Don't worry, dear friends, there will
not be a test at the end of this article
but…..you can go to jail for messing things up.
I don't want any dentist incarcerated for
accidental fraud, but I do want you to feel
great about treating your Medicare patients
and getting the most out of these plans for
them and for you.
To clear up a common misconception about
coverage, Medicare will never pay 100% of
covered services. In fact they only pay 80% of
allowable services or UCR to participating
providers and reimburse 70% of a reduced
allowable to patients who choose nonparticipating providers. This is why supplemental plans are very popular with Medicare
recipients. Supplemental is additional insurance coverage that can be purchased to cover
the difference and capture 100% coverage of
the allowable charge or UCR fee set by Medicare. Here is a simple rule to understand
supplemental insurance. If Medicare does not
pay then supplemental won’t pay. An easy way
to figure out what kind plan your patient has is
to look for the word Medicare or supplemental
on the card. If you don't see those words you
might have a bona fide secondary plan.
Secondary plans are completely different than
a supplemental, and by different, I mean
better! They will typically pay (depending on
the plan) over and above the Medicare allowed
amount. Please keep in mind, while Medicare
and supplemental plans do not require pre
authorization secondary plans typically do.
GoGo Billing always suggests a benefit call to
the secondary plan to see if they require
pre-auth prior to starting services. In addition
to the allowable or UCR being higher then
Medicare, you can also bill out your exam,
x-rays, AM aligner, follow-up visits, and followup sleep studies.
When billing for a patient who has a true
secondary plan, accepting the assignment of
benefits can bring you right back to square
one and turn it into a supplemental. NOT
GOOD! To clarify, when you mark on the claim
“accept assignment of benefits” to Medicare
this means you are billing as a participating
provider and you cannot balance bill over the
allowed amount. So a true secondary will just
pick up the 20% of the non-covered allowed
UCR. This one little box can cost hundreds or
even thousands in lost claim payments. The
tricky part with non-participating claims in
which you can bill the patient above the
Medicare fee is that the Medicare payment will
go to the patient and the secondary may as
well. If you are not collecting your full fee up
front then you should always have the patient
sign an assignment of benefits form as well as
an agreement to turn over all insurance
payments and EOB’s to the office. The ever
important ABN form is always recommended
for all Medicare patients to sign regardless of
their plan. While the insurance companies will
not help you run after your money they do not
look kindly upon theft. Many commercial
insurance companies have written in their plan
benefit documents that if any payments are
kept for services the subscriber has received
and not paid the provider for, it’s considered
grounds for termination and they can be
dropped from the plan. This a risk most sane
subscribers are unwilling to take.
Replacement plans are the plans we
should anticipate getting if they are
still available when we hit the
magical Medicare age. They are
exactly what you are assuming they
are. They replace Medicare and are
commercial insurance plans. For
the “opted out” Dental office, they
are the only Medicare patients
whom you can see and get some
reimbursement. They have their
own guidelines for meeting medical
necessity and there are no restrictions about which appliance you
can use.
In summary:
Medicare is ok.
Supplemental is good.
Secondary is better.
Replacement is best.
If you are expecting above
the Medicare allowable,
don’t check the box! Please
don’t forget to sign up for
Part B status before June 1st
and email me if you would
like any of the forms mentioned above.