Medicare as Secondary Payer


Simply because a patient has Medicare should not be reason to automatically assume medical billing claims should be sent directly to Medicare. There are several instances where Medicare will, in fact, function as a secondary payer for medical claim billing. Filing such claims incorrectly can cause significant delays in payment, not to mention administrative headaches. These problems can be avoided if you know what to look for and what questions to ask – here are some cases where Medicare serves as a secondary payer for medical claim billing.

Over 65 and working

Medicare beneficiaries over 65 who continue working and are enrolled in an employer sponsored health plan are required to file Medicare billing claims as secondary. The employer sponsored health plan will almost always be the primary carrier for initial claim determination.

Over age 65 and covered by a working spouse

similar to above, if a Medicare beneficiary is enrolled as a dependant in the employer sponsored health plan of an employed spouse, Medicare billing claims will also be filed as secondary.

Workers' Compensation Claims–

Medicare will be the secondary insurance for medical claim billing if the claim falls under state or federal workers' compensation regulations.

Auto and Liability Insurance–

Treatment or care covered under automobile, no-fault, or liability insurance will be submitted to Medicare as secondary.

End Stage Renal Disease (ESRD)

Medical billing claims for Medicare beneficiaries diagnosed with ESRD and covered by an employer sponsored health plan are typically filed with Medicare as secondary through an initial 30 month coordination period.

Medicare Disability–

Beneficiaries under 65 and entitled to Medicare as a result of a disability will also require medical claim billing with Medicare as secondary if the beneficiary is also covered under a large group health plan.

This list only covers a few circumstances where medical claim billing is filed with Medicare as secondary; more detailed information is available in the Medicare Secondary Payer Manual . Also, consider working with a professional medical billing company who can further ensure you are on top of the latest information from Medicare and commercial carriers.

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