Coordination of Benefits with Double Coverage - Medical Insurance

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Mar 23, 2019
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#1
I have double medical coverage but have a question about how this works.
Let's say I have a bill for $100 for simplicity.

If I have only one coverage and the write off amount is $25 so the contracted amount is $75. The Insurance Company pays $50. I am responsible to pay the $25. ($100-25 = $75-$50=I owe $25)

But when I have double coverage:
My primary coverage has a write off of $25 so the contracted amount is $75.00 and then they pay $50 of the claim.
My secondary insurance company has a write off amount of $15 so the contracted amount is $85.00 and then they pay $40 of the claim.
In this instance the Doctor receives $50 + $40 = $90 for this claim; $15 more than if I only had one insurance. Yes I don't have to pay anything but the doctor receives more for me paying for double coverage. Should the doctor's office have to reimburse me $15 since they are being paid more than the contracted rate they agreed to or at least apply it to other claims that are not fully covered?
 
Jan 6, 2015
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#2
Typically, I believe, secondary insurance only pays what the primary does not (not including deductibles). So in your example, the primary contract amount of $75 leaves $25, which the secondary may pay for you. So the best you can expect is to pay nothing . . .
 
Mar 23, 2019
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#4
Typically, I believe, secondary insurance only pays what the primary does not (not including deductibles). So in your example, the primary contract amount of $75 leaves $25, which the secondary may pay for you. So the best you can expect is to pay nothing . . .
Thank you for your response.
However, when I look at my Explanation of Benefits (EOB) in some situations since both of the insurances are paying the doctor, the doctor is getting more than the contracted rate; in this example the doctor is receiving $90 instead of the contracted rate of $75.
 
May 15, 2016
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#6
It sounds like the two insurances each acted as primary insurance, instead of one acting as primary and one as secondary. Apparently one company does not know about the other. So it probably was not processed correctly. I assume this is a married couple, each having full insurance from their respective employer, most of which is redundant and wasted. Since most employees now share the cost of their coverage with their employer, it is often beneficial for one of the spouses to decline insurance from their employer if possible. The savings on the cost share would probably cover your copays and then some.
 
Dec 19, 2014
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#7
I have double medical coverage but have a question about how this works.
Let's say I have a bill for $100 for simplicity.

If I have only one coverage and the write off amount is $25 so the contracted amount is $75. The Insurance Company pays $50. I am responsible to pay the $25. ($100-25 = $75-$50=I owe $25)

But when I have double coverage:
My primary coverage has a write off of $25 so the contracted amount is $75.00 and then they pay $50 of the claim.
My secondary insurance company has a write off amount of $15 so the contracted amount is $85.00 and then they pay $40 of the claim.
In this instance the Doctor receives $50 + $40 = $90 for this claim; $15 more than if I only had one insurance. Yes I don't have to pay anything but the doctor receives more for me paying for double coverage. Should the doctor's office have to reimburse me $15 since they are being paid more than the contracted rate they agreed to or at least apply it to other claims that are not fully covered?
How primary and secondary coverage should work.

You have a $100 bill. Insurance A pays $50 of the claim. The balance of $50 is then forwarded to insurance B, and they $40. The doctor is still only receiving $90 for a $100 bill. Why would you think they should reimburse you anything? They haven't been paid in full. If for some unknown reason insurance B pays $60 and the total payment is now $110, the doctor's office would need to reimburse the $10 to the INSURANCE company, not you.

The total payment made by insurance A and insurance B cannot exceed to total amount of the bill. In your situation, theoretically, the doctor's office can bill you the $10.

Now, you are mentioning contracted rates. Is insurance A medicare? Because that changes the equation, because Medicare is an insurance company that has a maximum rate/contracted rate. If that is the case, the total payout from insurance A + insurance B cannot exceed the maximum allowable. But I have yet to ever hear of a situation where insurance B will pay more than the difference between the gap, because insurance B reimburses based on the balance.

Insurance B also cannot act as a primary if insurance A is medicare.

Unfortunately, your hypothetical situation doesn't mimic real life, and ultimately what you are owed and potentially refunded is going to be dependent on the specific contracts you have with insurance A and B. There are many scenarios so the simplified version that you presented may not represent what is actually happening.
 
Dec 19, 2014
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#8
Let me be more specific in your situation.

Bill $100
Maximum contracted rate $75
Insurance A pays $50
Insurance B should only be billed $25. If it is billed $100, then it was submitted incorrectly, and it needs to be fixed.
Insurance B's maximum payout should be $25. It should not exceed $25.
If insurance B paid more than $25, in 99.9999% of the times, an error was made in the payment or process.

whether you are entitled to any excess payments over $75 depends on the contact between the physician and the insurance company. If it is Medicare, it cannot exceed $75. Other insurance companies may allow the office to keep the excess, but there isn't enough information that you have provided. There are over 8000 different insurance contracts and the insurance contract spells out what is owed to you.
 
Jan 6, 2015
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#10
To further woodworker's point, Medicare states (under "I have more than one other type of insurance or coverage":

If you have Medicare and more than one other type of insurance, check your policy or coverage. It may include the rules about who pays first.
 
Likes: Neil Maley

jsn55

Verified Member
Dec 26, 2014
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#11
How primary and secondary coverage should work.

You have a $100 bill. Insurance A pays $50 of the claim. The balance of $50 is then forwarded to insurance B, and they $40. The doctor is still only receiving $90 for a $100 bill. Why would you think they should reimburse you anything? They haven't been paid in full. If for some unknown reason insurance B pays $60 and the total payment is now $110, the doctor's office would need to reimburse the $10 to the INSURANCE company, not you.

The total payment made by insurance A and insurance B cannot exceed to total amount of the bill. In your situation, theoretically, the doctor's office can bill you the $10.

Now, you are mentioning contracted rates. Is insurance A medicare? Because that changes the equation, because Medicare is an insurance company that has a maximum rate/contracted rate. If that is the case, the total payout from insurance A + insurance B cannot exceed the maximum allowable. But I have yet to ever hear of a situation where insurance B will pay more than the difference between the gap, because insurance B reimburses based on the balance.

Insurance B also cannot act as a primary if insurance A is medicare.

Unfortunately, your hypothetical situation doesn't mimic real life, and ultimately what you are owed and potentially refunded is going to be dependent on the specific contracts you have with insurance A and B. There are many scenarios so the simplified version that you presented may not represent what is actually happening.
I believe our OP is asking about "double insurance coverage", not primary and secondary.
 
Dec 19, 2014
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#12
@woodworker is correct. There are scenarios where Medicare is secondary. The responses highlight the biggest issue that no one is focusing on.

The mere fact that the OP is providing a hypothetical scenario and asking what is right CANNOT be answered because there are too many scenarios. Without specific details, the exact answer CANNOT be answered, because there are missing details.

@jsn55 I do not believe it is possible to have double primary coverage. Then again, there is probably a scenario where it is possible,