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🇺🇸 Secondary Claims in Jane

This guide walks through how you can manage patients that have secondary or supplemental insurance coverage - where the client has multiple insurance policies(i.e. primary and secondary insurance).

Invoicing a visit with dual coverage at the time of service

When a client is covered under a single policy (their ‘primary’ policy), you can simply add the client’s policy to the appointment to create a claim under that policy. At the time of service, you’d then enter the relevant billing codes, and collect any known patient responsibility (i.e. a copay). Likewise, you have the opportunity to add in billing code Allowed Amounts.

When a client has dual coverage, time of service invoicing changes slightly! For visits with dual coverage, if you add patient responsibility (i.e. a Copay) to the primary claim, that amount will be passed to the secondary instead of the patient.

That said, the primary Copay can be passed directly to the patient (bypassing the secondary) when recording the remittance/EOB for the primary. To bypass the secondary insurer, just be sure to select the Collect from Patient option under your patient responsibility (i.e. Copay) when posting the primary EOB.

 

Let’s walk through an example - Time of Service

Let’s say Dr. Marcus bills out two codes - 99203 & 98941 - with respective rates of $150 and $50 to his client Jordan Smith’s primary insurance.

Dr. Marcus is in-network with Jordan’s insurance (Blue Cross / Blue Shield) so he knows how much they will allow for both the codes he’s billing out - $85 for 99203 and $45 for 98941. Dr. Marcus also knows that Jordan has a 20% coinsurance that he would like to collect at the time of service.

Here’s how that would look:

Note how the Allowed Amounts affect the invoice. They represent the total amount that Dr. Marcus expects to collect from both the patient and the insurance company (insurer payment + patient responsibility). The patient invoice is $26 (20% of $85 + 20% of $45), and the insurer invoice is $104 (Billed Amount - Un-Allowed Amounts - Patient Responsibility). The difference between the Billed Amounts and the Allowed Amounts, or ‘Un-Allowed Amount’ ($200-$130 = $70), is adjusted off of the invoicing at the time of service.

Note that the invoiced amounts won’t affect your claim submissions, as Jane only uses the Billed Amounts on CMS1500s and EDI files.

Now let’s spice up the scenario and say that Jordan also has secondary insurance coverage. 🌶

When we add Jordan’s secondary insurance coverage to the visit, here’s what happens.

  • The primary insurer invoice is unchanged (still $104)
  • The patient invoice changes from $26 to $0 (Jane assumes the secondary will cover the Coinsurance)
  • The secondary invoice is created for $200 (assuming no Allowed Amounts are present).
  • The total Billed Amount (sum of the procedures) is $200 and the total visit invoicing of this visit is $304 (primary + secondary + patient invoices)

You may be wondering why the total invoicing of the visit is greater than the procedures being billed ($304 when combining the primary and secondary invoices vs the $200 in procedure codes). 🤔

This is because Jane treats the invoicing of each claim independently at the time of service. Each claim (i.e. the primary and secondary claim) has its own set of billing code Allowed Amounts that reflect the billed procedures. The Allowed Amounts determine the invoice amounts for both claims at the time of service.

This mirrors how claims are treated in the submission process. When billing a secondary claim, you still need to bill the full amount of the billing codes along with the primary EOB/Remittance.

If Dr. Marcus knows what Jordan’s secondary insurance is going to allow for each procedure, he can add Allowed Amounts to the secondary claim at the time of service to make his accounts receivable for the secondary invoice more accurate before recording the response from the primary insurer (recording the primary EOB).

Let’s say that Dr. Marcus knows that the secondary insurer allows $40 for 99204 and $5 for 98941.

Here’s how the invoicing would change if you added those Allowed Amounts to the secondary claim:

  • The primary insurer invoice is unchanged (still $104)
  • The patient invoice remains $0 (since no patient responsibility was entered in the secondary)
  • The secondary invoice updates from $200 to $45
  • The total Billed Amount (billing codes) is $200 and the total visit invoicing is $149

If you’d like to learn more about how to manage these secondary claims either manually or electronically in Jane, click below!

If after reviewing the links above more questions come up, we’re happy to help! Use the Help button from within your Jane account or email us at [email protected]. 🙂