Question
QUESTION: I sent a more complex version of this question to John P, who declined
Am sending a more succinct version with less judgment to the question. Hopefully you can help.
Im new to Medicare due to disability . Wife is retired, both under 65. We both have GHP still in force from our employers, (they are not "Medicare Plus" plans ). Medicare A/B pays first for me but I notice less rate paid than GHP had usually paid for the same items.
GHP COB language says they will COB with all other plans for up to 100% of GHP R&C usual rates in total. However, do Medicare contracts with providers typically permit or prohibit provider from billng secondary GHP for R&C rate difference, over and above any Medicare deductibles?
ANSWER: Medicare will pay 80% of the allowed amount and the GHP will pay the 20%of the allowed amount that Medicare did not pay. The provider must submit the copy of the Medicare payment to the GHP. The provider is not actually billing a fee to the GHP but showing them what Medicare allowed and paid.
---------- FOLLOW-UP ----------
QUESTION: As a followup, are you just referring to the Medicare part B coinsurance percentage? What if in addition to coinsurance, the GHP allowed amount is 30% higher than the Medicare allowed amount? May the provider bill the 30% to the GHPs if does not accept Medicare assignment at the lower allowed amount?
Is that provider Medicare assignment decision permitted on an individual patient basis, or do Medicare rules require an the assignment decision on a provider wide basis?
Answer
If a provider is participating with Medicare, in other words, has a contract to accept Medicare allowed amount as payment in full then it is across the board for all. If they are non par, then they can accept assignment or not on a patient by patient basis.
I think you should call Medicare for your questions as I would need more information. Calling them is the best way to go. It is different when GHP is secondary instead of primary to Medicare.
