By Ranadene (Randi) K. Tapio, MBA, CMRS, CMC, Guest Contributor bio
When patients have multiple insurance coverage, at times it can be difficult to determine which one is primary, secondary, and tertiary. Sometimes, the patients don’t even know which order they go in!
While there are always going to be exceptions, here are some basic guidelines to keep in mind:
Medicare
- Medicare is usually primary.
- An exception to this is if the patient and/or their spouse are still working and they have a group policy through their employer. In this case, the insurance through the employer is most likely primary.
- Oftentimes, Medicare patients have Medicaid as their secondary insurance.
Medicare Replacement Plans/ Medicare Advantage Plans
- Some common plans are Unicare, Humana, Secure Horizons Direct, Medica, and UCare Seniors. Some commercial carriers also offer these types of plans.
Dual Employer Sponsored Group Policies
- Married patients may have two insurances if both people are employed and have group policies through their employer.
- In this case, the patient’s own policy is their primary. And their spouse’s policy is their secondary.
Minor Children with Dual Employer Sponsored Group Plans (under parent/guardians employer)
- When the patient is a minor, and both parents hold insurance on the patient, then the “birthday rule” is used: whoever’s birthday is first in the calendar year. For example, mom’s birthday is 02-01-1956 and dad’s birthday is 11-01-1954. In this scenario, mom’s insurance would be primary to dad’s Even though dad is older by birth year, mom’s birthday falls first in the year (2 = February, 11 = November).
Medicaid: Always the payer of last resort.
- These are state-funded programs that require need and income guidelines to be met.
- No exceptions.
Conclusion
Ultimately, it is the patients’ responsibility to know their insurance coverage, and which order they go in., but following the above guidelines should assist you in helping your patients, as these are the most common scenarios usually encountered. The longer you work in this field, the more you will learn on-the-job over time.
Ranadene Tapio is the president of MedCycle Solutions, which provides Revenue Cycle Management, Credentialing, Outsourced Coding, and Consulting Services to a number of healthcare providers in a variety of specialties. She holds an MBA in Healthcare Administration & Management and multiple professional certifications. You can reach her at Randi@MedCycleSolutions.com or call 320-290-6448.
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