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Dragonfly64

(45 posts)
2. I've managed a medical office for 23 years
Wed Jan 31, 2018, 06:01 PM
Jan 2018

and I handle the insurance. Because the provider was out of network your primary insurer sent payment to you and they expect you to be billed by the doctor, so that payment is correct. The real question is whether the Medicare claim was handled properly. Medicare Part B ordinarily pays 80% of allowed charges (after deductible) with the remaining 20% due from the patient or a secondary insurance policy. Since her Medicare is secondary coverage, it's not surprising that they would pay the balance AFTER the primary payment if the balance doesn't exceed their fee schedule. The big question is whether Medicare is aware that your wife has a primary insurance and, if so, did the doctor's office file the claim to Medicare along with the primary benefit information? Any over-payment would more than likely be due to Medicare and the responsibility of the doctor. If I were you I would get a copy of the Medicare explanation of benefits (eob) to see how they processed the claim.

Also - if there are other in-network providers in your area then your primary insurer is probably not going to reprocess the claim as if it were in network. They usually only do that if there is nobody in network available in your area or if it was an emergency situation.

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