Question

As with a Medicare RA, when a commercial RA is received, before posting payments and preparing secondary claims that may be required you must carefully review it. When analyzing an RA from a commercial carrier, you must be familiar with the guidelines of that carrier’s particular plan. The type of services covered and the percentage of the coverage will vary, depending on whether the plan is a fee-for-service plan, a managed care plan, a consumer-driven health plan, or some other type. The allowed amounts for each procedure will also vary with different plans, depending on the fee schedule decided upon in the contract between the payer and the provider. The contract will also specify whether there is a discount on the fees.

 

In Claim Case Study 16.4, an RA is received from Anthem BCBS that is a fee-for-service plan with an 80-20 coinsurance and a $250 deductible. The first page of the RA shown in Figure 16.4 contains claim information for two patients who have secondary insurance plans through their spouses. (The primary claim for both patients was created in Chapter 15.) Answer the following questions based on the information in the RA before preparing the patients’ secondary claims.

1. What is the name of Karen Giroux’s secondary insurance plan?

 

 

2. Based on the RA, how much has Karen Giroux paid up to now toward her 2029 deductible? How much of her deductible is due with this claim? Once she pays this amount, what percentage of her claims will be covered by her secondary plan?

 

 

3. What amount does Karen Giroux owe for procedure 99386?

 

 

4. Anthem BCBS has paid Dr. Ronkowski $104 for Karen Giroux’s claim. How was this amount calculated?

 

 

5. What percentage of the eligible amount has Anthem BCBS paid for Jean Ruff’s claim? Based on the RA, has she met her $250 deductible?

 

 

6. What amount does Jean Ruff owe for procedure 99202? What percentage of the eligible amount does this equal?

 

 

7. Suppose that Jean Ruff had not met any portion of her deductible and was responsible for the full eligible amount of procedure 99202, $75. Would it still be necessary to send a secondary claim?

 

 

8. Based on the RA, calculate how much each patient is responsible for on the primary claim. Then estimate how much you think each secondary payer will pay. Note the following:

 

> The guarantor for Karen Giroux’s secondary coverage, her husband Jack, has met his deductible.

> Jean Ruff’s secondary coverage, provided through her husband’s plan, pays for 100 percent of covered services and has a $15 copay.

 

Patient: Giroux, K.

 

Patient Responsibility on Primary Claim: 

 

Estimated Amount from Secondary Payer: 

 Anthem BCBS

 

Patient: Ruff, J.

 

Patient Responsibility on Primary Claim: 

 

Estimated Amount from Secondary Payer: 

 Aetna Choice

Answer 1

Commercial RA/EOB Analysis

1. Anthem BCBS

2. $200; $50; 80 percent

3. $76 ($50 to fulfill her 2016 deductible plus $26 patient liability)

4. The allowed amount for the procedure is $180. The carrier will pay for 80 percent of covered services once the deductible is met. In this case, $50 is owed toward the deductible. Therefore, the amount due for the service is reduced to $130 ($180 -$50 deductible). Anthem BCBS then pays 80 percent of $130 to the provider, or $104.

5. 80 percent; yes

6. $15; 20 percent

7. Yes, a secondary claim should be sent to the secondary payer so that the payer has a record of benefits received or denied from the primary payer as well as how much Jean Ruff has paid toward her deductible for the year.

8. Giroux: $180; $20.80 (80% of $26.00, assuming that her secondary plan covers the routine annual physical)

Ruff: $75; $0 (100% of $15 = $15, minus the $15 copay)

Preparing Secondary Claims

See the answer keys for Claim Case Studies 16.4 A-B below for Anthem BCBS patients, Giroux and Ruff.

ANSWERS TO CALCULATING PATIENTS’ BALANCES

CLAIM CASE STUDY	PATIENT	PATIENT BALANCE
16.5	Wendy Walker	$0
16.6	Walter Williams	$0
16.7	Donna Gaeta		$126.80
16.8	Lakshmi Prasad	$23.60
16.9	Joseph Zylerberg		$15
16.10	Shih-Chi Yang	$0
16.11	Andrea Spinelli	$0
16.12	Nancy Lankhaar	$0
16.13	Donald Aiken		$0
16.14	Eric Huang		$34.60
16.15	Isabella Neufield		$0
16.16	Alan Harcar		$50.00
16.17	Jose Velaquez		$0
16.18	Wilma Estephan		$7.00
16.19	John O’Rourke	$0
16.20	Sylvia Evans		$0
16.21	Karen Giroux		$7.20
16.22	Jean Ruff		$15
16.23	Mary Anne Kopelman		$0
16.24	Otto Kaar		$0

Claim Case Study 16.4 A

Claim Case Study 16.4 B