One of the most difficult things to maneuver is coordinating benefits between two insurance companies. The most common questions involve what you can bill the insurance companies and the patients. Here are a few fundamental points to keep in mind.
Always bill your full fee and let the insurance companies make the proper adjustments, per your PPO contract. This ensures that your patients receive the maximum benefit. This also makes any patient refund calculation much easier. If you are a PPO provider for the primary and/or secondary plan, always calculate the patient balance using the lowest fee schedule. This means you may have to do some adjustments to determine if the patient actually owes a balance or if you actually owe a refund.
Now let’s step through two examples.
Primary plan is a PPO, the secondary plan is a non-PPO, and insurance companies coordinate benefits in full.
Crown PPO fee: $800
Crown full fee: $1,000. The full fee of $1,000 is used to bill both insurance companies.
Amount billed for crown $1,000
Primary PPO insurance pays $ 400
Secondary insurance pays $ 500
$ 100
Does the patient owe $100? The answer is “no.” The patient’s balance is calculated using the lowest fee schedule, meaning you use the PPO fee of $800 and subtract that from total reimbursements from primary and secondary coverage which equal $900 ($400 + $500). Does the practice owe a $100 refund? No refund is due since total payments of $900 did not exceed the practice’s full fee for the crown of $1,000. The practice would write off the $100 balance as a PPO discount.
The facts are the same as above except the insurance companies do not coordinate in full.
Crown PPO fee: $800
Crown full fee: $1,000. The full fee of $1,000 is used to bill both insurance companies.
Amount billed for crown $1,000
Primary insurance pays $ 400
Secondary insurance pays $ 100
$ 500
What does the patient owe? Remember to use the lowest fee schedule for the calculation. In this case the patient owes $300 ($800 PPO crown fee – $500 collected from both insurance plans). The remaining $200 balance is written off as a PPO discount.
Coordination of benefits can get confusing. Keeping these fundamental concepts in mind will help your team accurately calculate patient balances and refunds.