Happy Spring to you!  Although the calendar says it's spring, last week as I was leaving for the airport it was a balmy 37 degrees here in Massachusetts…brr.  And we are the lucky ones!  There was a blizzard forecasted for the Midwest!  I am certainly looking forward to warmer days, more sunshine and more daylight hours! 

It has been a very busy winter for us here.  We moved our office location to a beautiful old farmhouse in Newburyport.  We now have lots of windows with natural light streaming in and a wide open environment for our team to collaborate in.  With a full team of expert billers under the same roof the sharing of information about what’s happening in the industry is over the top!  One of the conversations that came up during a recent lunch meeting was the confusion surrounding coordination of benefits and how to handle it appropriately. 

I think we can all agree that coordination of benefits between carriers is getting more and more difficult.  The rules vary significantly from carrier to carrier and plan to plan.  An ERISA plan coordinates differently than a traditional plan.  Self-funded plans have their own set of rules and guidelines and it is difficult from a provider’s perspective to determine which plans are self-funded and which are not. 

We are seeing some secondary carriers no longer coordinating line by line but rather with the claims totals instead.  This can be a nightmare to determine patient responsibility, write offs, etc.  Other carriers are coordinating benefits and we can determine that from the numbers they are reimbursing, however, they are not spelling it out on the eob any longer that they did coordinate benefits.  So how do you know?  Some carriers will coordinate up their fee schedule, others will coordinate up to the lowest fee schedules and there are still a few that will coordinate up to UCR.  COB and determining writes off is one of the most challenging issues when posting payments and adjustments.  State laws vary, contractual obligations vary and guidelines vary.   

A  good rule of thumb to follow is to take into consideration that a coordination of benefits should benefit the practice but more importantly it needs to benefit the patient in the end.  Their out of pocket should not be higher when a provider coordinates benefits; it should benefit the patient.  Do not post any adjustments until all carriers have processed the claim; once that is complete then you can determine the correct write off if any.  Keep in mind a patient should not receive back more than they paid to you.  I have seen some offices post both sets of adjustments (primary and secondary) and then end up with false credits on their accounts.  In some cases money has been sent to patients for more than they even paid!    

If you are an in network provider, always check your contractual obligations and follow the guidelines.  Make sure you are not adjusting off more than you need.  If you are not in network with either carrier then be certain you are not collecting more than the charge.  I hope this helps!

We are going to be discussing this and many more similar topics at my upcoming seminar in Andover, MA on May 1^st : “A 360° Review Your Accounts Receivable”.  I hope you will join us and register for a full day of everything billing related!  Seats are still available!

Until next time Keep Calm and Code On!

TERRI