When Your Client Has Medicare AND Another Policy

By Barbara Griswold, LMFT

(March 15, 2012)

When a client is covered by two insurance policies, normally you would determine which is the primary plan and bill them first. A claim could then be sent to the secondary plan with a copy of the Explanation of Benefits (EOB) from the primary plan, showing how the claim was paid.

When a client has Medicare coverage as well as private health insurance, Medicare is the primary payer and the other plan is secondary. So you should always bill Medicare first, right? Not necessarily. Things get messy if you are one of the many providers not eligible to participate in Medicare, including Marriage and Family Therapists and Licensed Professional Counselors.

If you are a NOT a Medicare-eligible provider, the secondary plan essentially becomes the primary payer. But there’s a catch. “In the past, plans required providers or patients to submit denial letters from Medicare before the plans would pay out as a second party payer,” writes Catherine Atkins, JD, Deputy Executive Director of the California Assn. of Marriage and Family Therapists (CAMFT).¹ However, “Medicare changed its policy and no longer sends denial letters for services to Medicare patients,” says Atkins. “Because providers were unable to garner denial letters from Medicare for the treatment, they were unable to submit the claim to the secondary plan for processing and payment.”

So what should you do? Plans each have their own policies for handling this situation – or may be in the process of formulating them. According to CAMFT, some plans no longer require Medicare denial. Others require that you fill out a Coordination of Benefits (COB) form (often downloadable from their website), and attach this with your claim to the secondary plan, stating that you are not eligible for Medicare and thus unable to obtain a Medicare EOB or denial. You can sometimes simply state this in a letter attached to your claim. It may help to cite the specific code (Section 1861(s)(2) of the Social Security Act) which excludes LMFTs and LPCs as Medicare providers.

Bottom Line: Contact the secondary plan you are working with to find out their policies and the best way to handle this situation.

Final note: Does the client have a secondary policy, or a Medicare “supplement?” A “supplemental” policy is not the same as a secondary, and may also deny the services of a non-Medicare provider.

References:

1. “Medicare Reimbursement – How to Bill Third Party Payers,” by Catherine Atkins. The Therapist, Nov/ Dec 2011.

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Barbara Griswold, LMFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should. To purchase the book or other resources for therapists, click here. Contact Barbara at barbgris@aol.com to get answers to your insurance questions.

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