Claims Processing Classroom: Understanding Primary Insurance with Medicare

Posted by Shane Shepherd on Thu, May 07, 2015 @ 10:05 AM

Shane Shepherd is new to the VisionWeb team, and he brings with him tons of billing, coding, and claims processing experience from years of working with eyecare practices. You'll be seeing a lot more of him on the blog dropping all kinds of insurance related knowledge! Today, he is going to talk about a common question that he gets about primary, secondary, replacement, and supplemental insurance claims, specifically in regards to Medicare.

Claims Processing Tip: How to Understand Primary Insurance with Medicare

How do I know which insurance is Primary?claims processing classroom

For starters, it's not always easy to determine which insurance is primary, especially when Medicare is involved. Half the time patients don't recognize Medicare as insurance, or understand that it is applicable to their Optometrist visits.

So how does someone tell what type of coverage the patient has?

There are four choices: Medicare, Replacement, Supplement, and Secondary.

If a patient has a Non-Medicare insurance card but has "Medicare" printed on it, that card is likely going to be a replacement or supplemental policy, but which one is it?

It's an important distinction as Supplements typically pay what Medicare approves but doesn't actually pay. Examples of these charges are deductibles and co-insurance. A tell-tale sign that it's a supplement is that the card will usually list a "Plan" on the card, most common being Plan F. The Plan is the supplement, which makes Medicare the primary.

Someone that presents you with a card that mentions names like Medicare Advantage, Secure Horizons, or Medicare Gold is providing you with a replacement. It's replacing Medicare and that makes it primary. Your tipoff that it is a replacement plan is the mention of co-pays or deductibles along with a name similar to the plans highlighted above.

Lastly, if the card looks like any other insurance card - that is to say there is no mention of Medicare anywhere on it and it doesn't have a cryptic name that insinuates the patient is older (like Secure Horizons), then it's probably secondary to Medicare. That means it has its own set of benefits that aren't developed in relation to Medicare. Often those don't pay for copay and co-insurance.

Shane will be on the blog with more tips to help improve your claims management, so stay tuned!

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Tags: Tips & Tools, Electronic Claim Filing

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