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  1. #1
    Join Date
    Aug 2017

    Exclamation Who Gets the Difference Between Primary Insurer's Copay and Secondary Insurer Payment

    My question involves insurance law for the state of: Alaska

    We have a patient who has Aenta prime and Blue Cross second. Aetna's allowable is less than Blue Cross's. Blue Cross paid based on THEIR allowable, so they paid the copay left by primary and also the amount of Aetna's adjustment. We are contracted with both payers. The patient feels we should be giving her the difference between the copay left by her primary and what her secondary paid, which is about $115 per visit (we are physical therapy, so there are several visits). Blue Cross will not take a refund if we try to refund them. My understanding is that you go by the allowable of the secondary carrier if they differ. I tried finding something on the AAPC site. I have gotten what other providers do, which is what I just noted- go by the secondary's allowed, but I need to know the legality here.

    The patient is saying "all" of her other providers give her a check for the difference between the primary's copay and what the secondary paid, but I do not believe her. I feel she is trying to get money out of providers. It also does not feel right that we would give the patient money when she never paid a dime, only her insurances have and, like I said previously, the secondary will not take a refund. We are not getting anything above the amount we billed out to insurance either.
    I need some legal ground with this patient as she is VERY persistent in believing she is owed money by us. Please help me as soon as you can. I need to call her back in the next day or two.

    I appreciate any help you can give!

  2. #2
    Join Date
    Sep 2005
    Behind a Desk

    Default Re: Who Gets the Difference Between Primary Insurer's Copay and Secondary Insurer Pay

    If you received a payment from the customer and, as a result of the insurance companies' subsequent payments, have now received more than 100% of the amount due under the bill, the overpayment is refundable.

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