Maximizing Medical Billing Efficiency: Navigating Secondary Insurance With Medisoft

Billing secondary insurance claims can be a complex process, but it can be made smoother by following some best practices. Medisoft is a popular medical billing and accounting software that simplifies the process of billing. It is used by healthcare providers to input patient records, submit insurance claims, and manage patient receivables. The software has many user-friendly features, such as pop-up help windows and customizable toolbars, making it easy to learn and use.

When billing secondary insurance claims, it is important to first understand the difference between primary and secondary insurance. Primary insurance pays towards the claim first, while secondary insurance pays some or all of the remaining balance, which can include a copay. There are various scenarios in which a patient may have secondary insurance, such as having insurance through their employer and also having a government plan like Medicare.

To bill secondary insurance in Medisoft, there are a few steps to follow. First, collect up-to-date and accurate demographic information about the patient, including their name, birthdate, and insurance plan subscription information. Check eligibility and verify insurance for each insurance plan. Once you are ready to bill, submit the claim to the primary insurance plan. After the primary insurance processes the claim, note the allowable amount, patient responsibility, and any adjustments. Then, submit the claim to the secondary insurance, including the original claim amount, how much the primary insurance paid, and why they didn't pay the full claim. Finally, once the secondary insurance pays their portion, forward any remaining balance to the patient.

Understanding the difference between primary and secondary insurance

Having more than one insurance plan can be beneficial for individuals with high medical expenses or those who require specialised treatments. However, it is important to understand the differences between primary and secondary insurance to make the most of your coverage.

Primary Insurance

Primary insurance is the first policy responsible for covering medical expenses. It is typically the main source of coverage for an individual or family and is often obtained through an employer or purchased directly. The primary insurance is billed first when you receive healthcare. For example, health insurance received through your employer is usually your primary insurance.

Secondary Insurance

Secondary insurance is an additional insurance plan that a patient may have on top of their primary insurance. It is a supplementary policy that fills in any gaps or covers additional expenses not covered by the primary insurance. It is billed after the primary insurance and pays a portion of the remaining balance. For example, if you have insurance through your employer and also enrol in your spouse's health insurance plan, your spouse's coverage would become your secondary insurance.

How They Work Together

The process of coordinating the benefits of primary and secondary insurance is called the coordination of benefits (COB). This ensures that each insurer pays their fair share without paying more than 100% of the total medical costs. The primary insurance pays first, up to its payout maximum, and then the secondary insurance pays its portion, up to its limit. If there is still a remaining balance, the policyholder is responsible for paying it.

Determining Primary and Secondary Coverage

There are no universal rules for determining which insurance plan is primary and which is secondary. However, certain scenarios can help you identify which of your health plans fall into each category. For example, if you and your spouse both have employer-sponsored insurance, your plan is typically primary, while your spouse's plan is secondary. For children with parents who have separate insurance plans, the parent whose birthday comes first in the calendar year is usually the primary insurer.

When to bill secondary insurance

• Understanding Primary and Secondary Insurance: Primary insurance pays first for a patient's medical bills, while secondary insurance pays after the primary insurance. The secondary insurance typically covers some or all of the remaining costs, such as deductibles, copayments, or coinsurance.
• Determining Primary and Secondary Insurance: When a patient has multiple insurance plans, it's essential to confirm which one is their primary coverage. Usually, a patient's coverage from their employer is the primary insurance, while coverage from a spouse or parent is secondary. If a patient has both Medicare and employer coverage, the employer-based insurance pays first if the company has 20 or more employees; otherwise, Medicare pays first.
• Coordination of Benefits (COB): When a patient has both primary and secondary insurance, the two plans coordinate through COB to ensure they don't pay more than 100% of the total bill. The COB uses industry regulations to establish which insurance plan is primary and pays first. It's important to confirm the COB before submitting a secondary insurance claim to avoid delays and additional follow-up work.
• Billing Process: Healthcare providers cannot submit claims to both primary and secondary insurance simultaneously. First, submit the claim to the primary insurance and wait for their payment. Then, submit the claim to the secondary insurance, including the initial billed amount, the amount paid by the primary insurer, and the reasons for any unpaid portions.
• Timing of Secondary Insurance Claims: You can submit a claim to the secondary insurance once you've billed and received payment from the primary insurance. It's crucial to remember that you cannot bill both insurers at the same time, as insurance companies have strict rules to ensure they don't pay more than their allocated portion of the bill.
• Common Scenarios: There are several situations where a patient may have multiple insurance plans. For example, individuals over 65 who are still working might have both Medicare and their employer's plan. Spouses may enrol in each other's employer policies, and younger adults under 26 might be covered by both their employer's plan and their parent's plan.
• Preventing Secondary Insurance Claim Denials: One of the main reasons for secondary insurance claim denials is a COB issue, such as billing the wrong insurer first or billing an inactive primary plan. It's essential to verify insurance and confirm the COB before submitting a claim. Additionally, secondary insurers may deny claims for missing information, so it's crucial to include all relevant details, such as the original claim amount, the primary insurer's payment, and any adjustments or explanations for unpaid portions.

How to add an insurance company in Medisoft

To add an insurance company in Medisoft, follow these steps:

• Go to "Lists" and select "Insurance" and then "Carriers".
• If you want to edit an existing record, highlight it and click "Edit". To create a new entry, click "New".
• Create a CODE, a short five-character identifier for the insurance company. For example, if the insurance company is "Medicare", you could use "MCR", "MEDIC", or "MCARE" as the code. Alternatively, you can leave this field blank, and Medisoft will generate a code for you.
• Enter the insurance company's NAME, STREET address, CITY, STATE, and ZIP CODE.
• Enter any relevant contact information in the PHONE, EXTENSION, FAX, or CONTACT fields.
• In the Plan Information section, enter the PLAN NAME.
• The CLASS field is optional but can be used to group similar insurance companies. For example, you can create a class for "Medicare of CA" and "Medicare of NV" to group those insurances.
• The NOTE field is also optional and can be used for your reference.
• Click on the "OPTIONS AND CODES" tab.
• The first set of options, PROCEDURE CODE SET and DIAGNOSIS CODE SET, allow you to use different CPT and ICD codes depending on the insurance being billed.
• Set the next three fields to SIGNATURE ON FILE.
• Set the PRINT PINS ON FORMS field to LEAVE BLANK, unless the insurance company requires IDs other than the NPI to print in 24j.
• Set the DEFAULT BILLING METHOD according to your preferred method of sending claims (paper or electronic).
• Specify default PAYMENT, ADJUSTMENT, WITHHOLD, DEDUCTIBLE, and TAKE BACK codes. This step is optional but recommended to save time during payment posting.
• Click on the "EDI/ELIGIBILITY" tab.
• Fill in the CLAIMS PAYER ID fields for the PRIMARY RECEIVER and SECONDARY RECEIVER sections. Only fill out the other fields if you are sending electronic claims.
• Under the CARRIER EDI SETTINGS section, select a TYPE from the drop-down menu, and check any relevant checkboxes. Contact support if you are unsure.
• Click on the "ALLOWED" tab.
• Enter the ALLOWED amount and select whether a code is UB NON-COVERED or not, once Procedure codes are set up.
• Finally, click "SAVE".

How to apply insurance payments in Medisoft

There are two different ways to enter insurance payments in Medisoft: on a case-by-case basis or in bulk via "Deposit Entry". The first method is preferable when entering insurance payments for a single patient, case, or date of service. The second method is more suitable when entering insurance payments for multiple patients from one insurance/check.

Entering Insurance Payments on a Case-by-Case Basis:

• Go to 'Activities', then select 'Enter Transactions'.
• Choose the desired patient chart and the corresponding case.
• Click 'New' in the lower half of the window, under the 'Payments, Adjustments, and Comments' section.
• A new payment line will appear. Enter the payment date and select a Pay/Adj Code.
• Select 'Who Paid' and optionally include a description such as a reference number or any relevant note.
• The 'Provider' field should default, but you can change it if needed.
• Enter the payment amount and check number, then click 'Apply'.
• Enter payments for line items as needed under the 'This Payment' column. The 'Complete' column should auto-check, but you can uncheck it if there may be further payments or if you don't want to shift responsibility to the next payer.
• Click 'Close' when finished. Repeat this process to enter additional payments or adjustments, and remember to click 'Save Transactions' when completely done.

Entering Insurance Payments in Bulk:

• Go to 'Activities', then select 'Enter Deposits/Payments'.
• Click 'New'. The 'Deposit Date' will default to the current date, the 'Payor Type' will default to 'Insurance', and the 'Payment Method' will default to 'Check'.
• Enter the check number and a description/bank number.
• Input the payment amount and select the insurance. The codes will default if set within the selected insurance; otherwise, select a code for each field.
• Click 'Save'.
• Back at the 'Deposit List' screen, select the desired payment/check and click 'Apply'.
• In the new window, select the patient for whom the payment should be applied. The patient's dates of service will appear.
• For any line items that should be paid, enter the payment amount. You can also enter the deductible, withhold, adjustment, or take-back amounts if applicable.
• The 'Complete' checkbox should auto-check when payment amounts are entered. However, you can uncheck it if there may be further payments or if you don't want to shift responsibility to the next payer.
• Click 'Save Payments/Adjustments' when finished with the patient. You will be prompted to print a statement, or you can click 'Cancel' if not needed. Continue selecting patients and entering payments/adjustments until you are finished.

How to submit a claim to secondary insurance

Submitting a claim to secondary insurance is a process that requires careful attention to detail and a good understanding of the patient's insurance plans. Here is a step-by-step guide on how to submit a claim to secondary insurance using Medisoft:

Step 1: Collect Patient Information

Start by gathering accurate and up-to-date demographic information about the patient, including their name, birthdate, and insurance plan subscription details. This information is crucial for verifying the patient's insurance coverage and coordinating benefits.

Step 2: Verify Insurance Coverage

Check the eligibility and verify the insurance coverage for each of the patient's insurance plans. If neither plan appears as primary insurance, contact the patient and advise them to update their Coordination of Benefits (COB) with their insurer. The COB specifies what each insurer is responsible for paying and helps determine the primary and secondary insurance.

Step 3: Identify Primary and Secondary Insurance

Confirm which insurance plan is the primary coverage and which is the secondary coverage. Usually, a patient's coverage from their employer will be the primary insurance, while coverage from a spouse or parent will be secondary. If the patient has both Medicare and employer coverage, the primary insurer depends on the company's size.

Step 4: Bill Primary Insurance First

Submit the claim to the primary insurance plan first. This is important because you cannot bill both primary and secondary insurance simultaneously. Wait for the primary insurance to process the claim and note the allowable amount, patient responsibility, and any adjustments.

Step 5: Prepare the Claim for Secondary Insurance

In addition to the regular billing details, you will need to include the total amount billed initially, the amount paid by the primary insurer, and an explanation of why the primary insurer didn't pay the full balance. Include the Explanation of Benefits (EOB) from the primary insurer to avoid potential delays or denials.

Step 6: Submit the Claim to Secondary Insurance

There are two ways to submit the claim to the secondary insurance: directly to the payer or through a claims clearinghouse. Submitting directly is more straightforward, but you are solely responsible for catching any errors in the claim. Using a claims clearinghouse adds an extra step, but it can help identify and fix any issues before submitting the claim, reducing the likelihood of denial.

Step 7: Follow Up and Bill the Patient

Once the secondary insurance has paid their portion of the claim, forward any remaining balance to the patient. Regularly follow up with the insurer to check the status of the claim and avoid delays.

By following these steps and staying organized, you can efficiently submit claims to secondary insurance and ensure a smooth billing process for your patients with multiple insurance plans.

Frequently asked questions