Secondary Insurance and Medicare

It is fascinating to me how rapidly and completely something can move from primary to secondary. I started writing this blog post one and a half weeks ago. After all sorts of interruptions, it has finally made it back to primary position in my task queue. Since I have no formal rules for how a task becomes primary or secondary, it can sometimes be a challenge to prioritize.

An active discussion on our SOS User Group site on Medicare Crossover claim filing started me thinking about this matter of primary and secondary insurance. Somehow, in our day-to-day lives, we have complete understanding of what these words mean, even if we have no formal definitions. When it comes to insurance, everything changes; the meanings and functions of primary and secondary become murky. Because we have addressed this issue here in this blog and in a couple of documents on our web site, internet searches for ‘filing secondary insurance’ often hit upon the article that Manon wrote on the subject or on the blog post. I am surprised at how frequently those searches and hits happen.

Our User Group discussion (just scroll to the top for the start of the thread) talked about the requirements placed upon Medicare Participating Providers to file secondary or crossover claims for their patients. Most of the participants indicated their understanding that it is necessary for Participating Providers to do this. Some discussants indicated that crossover claims are sent to the secondary insurer automatically. A couple of others indicated that there is some special process that they must go through to make this happen.

I know that one of the most important improvements in the 5010 version of the 837 claims transaction is requirement for the inclusion of more specific Coordination of Benefit information in the claim. Manon attended a Medicare webinar this week that discussed progress on meeting the 5010 requirements. Apparently, crossovers have been a big issue in this 5010 transition, but CMS indicates that they have made significant advance in working out the issues about crossovers.

Medicare regulations detail requirements for Coordination of Benefit Agreements and Coordination of Benefit Contractors. Unfortunately, wading through 124 pages of regulations to completely understand this process seems like overkill for an individual provider. Add to that the fact that different Medicare Administrative Contractors (MACs) may have different procedures, different Coordination of Benefit Contractors, and be in different stages of implementation of this process. In fact, a Google search for Medicare Crossovers comes up with documents created by many of the different MACs.

Getting your MAC to tell you what must be in your claims, what you as a provider are required to do for your patient, and what your patient may be required to do to complete the filing of secondary (crossover) claims seems like the reasonable course of action. I would be amazed if there is not detailed information on your MAC’s website.

Let us know if you are able to find out useful information. We can post the links here to make it easier for others to find what they need about the topic of Medicare Crossovers. Please share your comments below.

Medicare Fraud: CMS engages patients in fighting fraud

Do you have an elderly parent or friend? Have you ever taken a look at the Medicare Summary Notice (MSN) they receive each quarter from Medicare?

I don’t know when the last time was that my 92 year old mother looked at hers. I usually check it to make sure there is not some gross overbilling going on, but Mom ignores the statement. It is not the easiest document to review.

According to Karen M. Cheung at, Medicare is taking several steps to make it easier for elderly patients to review their monthly charges. The form and the website has been re-designed to make reviewing the explanation of benefits easier for the elderly Medicare subscribers who use the site. Sample


Drilling down by clicking on  

allows the user to see the details of the Medicare Summary Notice for each claim.

CMS is also making it more obvious that subscribers can earn a reward of up to $1000 for a tip that leads to uncovering fraud. That’s right . . . CMS will pay a Medicare recipient up to $1000 if their tip leads to finding actual fraud. Last year, consumer input resulted in $4 billion of savings, thanks to those who reported suspicious billing. On the MSN, just under the explanation of “How to Check This Notice”, the subscriber sees the following announcement:



Encouraging subscribers to report suspected fraud is one of the major ways CMS plans to save money. If by accident or on purpose, a provider bills for services not provided, for products not delivered, for medically unnecessary services or for misrepresented services, they become subject to a whole host of consequences based on the amount of money involved.

According to Wikipedia, The Office of the Inspector General for the U.S. Department of Health and Human Services is responsible to protect the integrity of HHS programs. The Office of Investigations for HHS works with the FBI to combat Medicare Fraud. The site has its own pages on Fraud & Abuse. The U.S. Department of Health & Human Services and the U.S. Department of Justice have created a site aimed directly at stopping Medicare fraud.

Clearly, this initiative is extremely important to CMS. We were recently surprised by a telephone call from someone claiming to be an FBI agent investigating one of our customers. Whether this was an unhappy patient, a disgruntled former employee, or an actual agent, we do not know. If we were to receive a supoena or request through proper channels, we might know more, but we would never provide information in response to a telephone call.

None of this is unique to the behavioral healthcare community, nor are mental health and addiction providers exempt from concerns about Medicare fraud. Abuses happen in all areas of healthcare.

What is your personal or professional experience with Medicare fraud or abuse? Does your organization have processes in place to prevent mistaken Medicare billing? We would love to hear about how you deal with these issues . . . short of not serving Medicare patients!

Please post your comments below.

Behavioral Health Administrative Workers: What are your employees worth?

A discussion with my coworkers recently reminded me of the wide variability in the size and nature of the organizations that utilize our software products. Behavioral Health organizations range from solo, part-time psychologists, psychiatrists, social workers and professional counselors in private practice to large community-based organizations that provide inpatient, outpatient, intensive outpatient, and home-based care to those requiring mental health and substance abuse treatment.

As a result of this wide variability, the individuals with whom we deal in our provision of technical support services range from highly-trained medical and mental health billing/coding specialists and practice business managers to the teenage child or neighbor of the doctor who happened to be in need of a summer job. We are often amazed by the differences…by how much some billing specialists know and how little information others have.

One of the biggest surprises for me is how often highly trained mental health professionals are willing to entrust their businesses to individuals who have no training to do such a job. We are sometimes asked why our software does not do “x” for them. We explain that the software is a tool to be used by someone who knows mental health/medical billing to accomplish the needed tasks. It will not magically do billing for someone who has no idea how to do that job.

My niece works in a medical practice and is studying for the American Health Information Management Association’s (AHIMA) Certified Coding Specialist – Physician Based exam. I went to AHIMA’s site to see what the content is for this certification and was amazed at the breadth of the knowledge required to achieve the certification. The AAPC is a different organization. . . of professional coders. . . that also offers training, certification, support and networking. Both of these are aimed at individuals who work in medical coding and billing.

Some people who work in behavioral health assume that the billing job must be much simpler for mental health because it contains a much narrower range of services than a general medical practice. Just ask any experienced behavioral health billing specialist, and you will find out that it is not simple at all. Just because the range of services provided in behavioral health is much smaller does not mean that the person doing the billing requires less knowledge about billing and collections and dealing with insurance carriers.

Mental health services were “managed” by insurance carriers much earlier than most other specialties. As a result, there are rules and requirements for obtaining authorization for treatment that have a 30 year history. While “parity” was legislated in 2008 and the final rule for implementation promulgated in 2010, implementation has been slow and many consumers are not even aware that their plan might cover mental health services at the same rate they cover general medical care.

To expect someone who has never worked in a health care setting and has not previously done medical or mental health billing to have any idea about parity or treatment authorizations or copays or coordination of benefits or take-backs is just not reasonable. Medical billing is complicated and behavioral health billing has its own subtleties and complexities that are different.

So what is an employer to do? Here are some quick suggestions:

  1. Recognize that the person who is doing your billing is running a crucial part of your business. You should expect them to be a business professional.
  2. Do NOT expect someone who earns minimum wage to know how to do behavioral health billing. If you find a qualified biller who is willing to work for such a wage, they are selling themselves short.
  3. If your staff is struggling with how to bill, get them information. The Center for Medicare Services (CMS) is an outstanding resource. If a claim will pass Medicare muster, it will also pass the requirements of most other insurers.
  4. Invest in training for your staff. Having your staff thoroughly learn the software product you are using will earn money for your organization.

This is an arena in which I am sure many of you have experience and opinions. Please share your comments below. If you have additional recommendations for employers, please let us know.

Electronic Claim Filing for Secondary Insurance

Our technical support and customer service staff regularly discuss questions our customers commonly ask. They often answers these questions in emails—repeatedly. For a long time, we have tried to answer some of these questions in documents to make it easier for our customers to succeed in their jobs. The Document Library page on our web site has always aimed to achieve that goal. This year, we implemented new and additional documents in a blog format on our web site as another way for our customers to get answers to their questions quickly.

Electronic claims filing is one of those areas where questions abound. No matter how many times we answer the same questions, we always need to come up with new and different ways to communicate information that is very familiar to us but not so apparent to our customers. This is the same kind of task psychotherapists and others who work with people in any capacity have to accomplish—coming up with different language and presentation of an idea so it can be heard and understood by the person being addressed.

Our lead technical support rep, Manon Faucher, recently wrote an article about how to file claims for secondary insurance carriers electronically. I have borrowed heavily from her article to address the issues that are crucial in successfully filing electronic claims for secondary insurance payers, assuming that the clearinghouse or site through which you send your electronic claims allows submission of secondaries and the payer to whom you are sending can receive secondary claims electronically.

In order to successfully submit secondary insurance claims, it is essential that you include the information about how the claim was adjudicated by the primary insurer. Doing so requires specific data in certain loops and segments of the 837P. If you are an SOS Software user, you should read Manon’s document. She created detailed instructions with screen shots for our product. If you use a different software product, you will need to find out from your vendor whether you can enter and they can report the necessary information to file the secondary claims.

  • Primary payer– You must be able to indicate the order of liability for payers. Make sure you have the Primary set as such for this claim.
  • Secondary payer– You must be able to designate this payer as Secondary for this claim. You must also be able to enter the “Amount received from other insurance”, information that would go in box 29 on the CMS 1500. This should go into the 2320 loop, segment AMT 02.
  • Verify the Claim Adjustment Reason (CAR) amount– If you have received an Electronic Remittance Advice (ERA) that automatically posted your payment from the Primary payer, you will need to determine that the total of the CARs matches the amount of the date of service Fee minus the payment from the primary insurance. Examples:

Denial – no payment by Primary

Fee for service $200
– Primary insurance did not pay for the service so $0 payment is entered for a Denial
CARs must equal the entire fee, $200.00

Partial Payment and Adjustment

Fee for service $200.00
– Primary insurance paid $120.00 and an adjustment of $30.00 was required from the payer
Amount of your CARs will have to equal to $80.00 ($200-$120)

The information from the CARs must be entered in the appropriate segment in the 2430 loop.

  • Adjudication or payment date: Make sure you have entered the payment date in the appropriate place so it will show up in loop 2330B segment DTP 03.
  • Generate and submit the secondary claim.

If your organization is not yet filing insurance claims electronically, it is certainly a service you should investigate. At some point in the future, it will certainly be required that all claims are filed electronically. In the meantime, it is a major convenience and financial savings for providers and organizations.

Maybe it is time for you to get rid of the paper!

Got any observations, opinions, reservations, cheers about filing claims electronically? Please share in the Comments section below. Thanks for reading!




Are your passwords HIPAA secure?

Standard advice for securing computer systems is to require users to change passwords frequently. Something about this recommendation has always bothered me, but I never really thought it through. A current blog posting at Healthcare Informatics by Dale Sanders really hits the nail on the head. He points out that these change-passwords-frequently policies actually undercut password security rather than enhancing it, once you factor in human psychology. If you have to replace your password frequently, you will probably come up with something simplistic, or resort to a post-it note on the monitor, or maintain a paper list. It would be far more secure to create a single, strong password or passphrase and continue to use it for a much longer period.

To manage passwords used on the web, you can’t go wrong with Roboform. Create a strong master password (long, and using a combination of letters, numbers, and special characters), then let Robo’s password generator suggest strong passwords for individual web sites. Once you select and use a password on a web site, Robo will remember and “type” it in for you when you next visit that site. All you have to do is enter your master password once in each browser session; Robo uses that to unlock your password library and cleverly selects the right one whenever you hit a login window. There is even a version of Roboform that you can install on a USB “thumb” drive, so you can securely carry your passwords with you for use on multiple computers, or even public computers when traveling.

In the course of providing technical support on our billing and EMR software, I am exposed to the password selections of many of our users. It is amazing how rare it is to find anyone using serious passwords. Names, almost surely loved ones or pets, are the most common, but way too frequently I see passwords that are identical to user IDs, or non-passwords like “123” and “password”. Although we have optional rules in our products that would require strong password choices if enabled, they rarely are used.

Coming up with an easily remembered, secure, master password is not really all that hard. Just think up a short sentence that includes punctuation and some numbers. You can check the quality of your choice using Microsoft’s password checker.

Here’s an example: “Turning 60! soon.” This easily remembered phrase is actually more secure than “3-vO$aLKG7”, which conforms to all the standard password creation advice.

Maintaining medical privacy is serious business. Current HIPAA rules provide for serious penalties when medical information is not properly secured. Are you guilty of password negligence yourself?

Seth Krieger

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