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Coordinating dual health insurance benefits.

Separate health insurance benefits that both cover a husband and wife can be good and bad. While multiple coverage is typically a good thing, it can be difficult to coordinate the benefits. It can also result in no payment.

For example, say you file a claim for your patient, and then she reports that her husband also has benefits. You postpone billing the second payer until you find out what the first payer pays. However, the first payer takes so long to pay the claim that the deadline for claim submission to the second payer passes, and you miss any chance of collecting from the second payer. While this should not happen with all the software technology available to payers and physicians, it does happen and should be monitored carefully.

Or perhaps your patient has her own insurance but fails to tell you that her husband also has insurance. Several months pass before you learn that the wife is also covered by the husband's insurance and that his is the primary policy. Again, however, the time for claim submission has passed, and you receive nothing at all. Even though federal and state laws determine primary and secondary payers, this won't help you if you don't know about the dual coverage.

Should such a circumstance befall you, you can appeal such denials. Also, some states have laws that permit extending the claims filing period in these situations. Check your contracts to see whether you are responsible if a patient does not inform you of additional coverage. The most effective practice, however, is to catch this problem early by asking your staff to be attentive to this issue. Also, always ask the patient, "Are you also covered by your spouse's insurance?" and "Which is the primary policy?" Finally, always have a signed financial responsibility policy in every patient's insurance file. Failure on a patient's part to inform you of current insurance information should not result in financial losses for you.

Steven F. Isenberg, MD

James R. Tate, MD; J. David Kriet, MD; Travis T. Tollefson, MD

From the Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Medical Center, Sacramento (Dr. Tate and Dr. Tollefson), and the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City (Dr. Kriet).
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Comment:Coordinating dual health insurance benefits.(PRACTICE MANAGEMENT CLINIC)
Author:Isenberg, Steven F.
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Sep 1, 2006
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