Yes, if your primary group health plan does not pay the entire cost of your medical bill—which includes instances of a full denial—your healthcare provider should then send the bill to Medicare for potential secondary payment.
When you have coverage from both a group health plan (such as through an employer or union) and Medicare, your group health plan typically serves as the primary payer. This means it processes and pays for your healthcare services first. Medicare then steps in as the secondary payer, covering costs that the primary plan didn't, provided the services are covered by Medicare.
Understanding Coordination of Benefits
The process that determines which insurance plan pays first is known as Coordination of Benefits (COB). For individuals with both a group health plan and Medicare, especially if the group plan is based on current employment, the group health plan usually holds the primary payer position.
- Primary Plan's Action: Your group health plan will receive the claim first. It will either pay a portion of the bill, or it might deny the claim entirely. Denials can occur for various reasons, such as the service not being covered under their policy, the patient not meeting deductible requirements, or a lack of prior authorization.
- Medicare's Secondary Role: If the group health plan does not pay the full amount of your bill—whether through a partial payment or a complete denial—your healthcare provider is expected to forward the remaining balance or the entire bill (in case of denial) to Medicare. Medicare will then evaluate the claim according to its own coverage rules and medical necessity criteria, determining any eligible secondary payment.
What Happens When a Primary Plan Denies a Claim?
When your primary group health plan issues a denial for a claim, it signifies that they have not paid any part of the bill. In this situation, it is the provider's responsibility to submit the bill to Medicare for consideration as the secondary payer.
Key Steps for Claim Processing After Primary Denial:
- Initial Claim Submission: Your provider first sends the medical claim to your primary group health plan.
- Primary Plan's Determination: The group health plan reviews the claim and either makes a payment or issues a denial.
- Secondary Claim Submission to Medicare: If the group health plan does not pay the full amount of the bill (e.g., if it denies the claim), the provider then submits the claim to Medicare.
- Medicare's Review and Payment: Medicare assesses the claim to determine if the services are covered under its guidelines, are medically necessary, and what its approved payment amount would be. If eligible, Medicare pays its portion.
- Patient Responsibility: You remain responsible for any costs not covered by either your group health plan or Medicare, which can include deductibles, copayments, coinsurance, or services that neither plan covers.
Example Scenario:
Consider a situation where you undergo a diagnostic test.
- Scenario 1: Primary Plan Denies Administratively: Your primary group health plan denies the claim because the test was performed at an out-of-network facility, or prior authorization was not obtained.
- Action Taken: Your provider should then submit this bill to Medicare.
- Medicare's Decision: Medicare will review the claim. If the diagnostic test is a Medicare-covered benefit and is deemed medically necessary, Medicare may pay a portion of the bill, even if the primary plan denied it for administrative reasons or specific policy exclusions. However, if the test itself is not a Medicare-covered service, Medicare would also deny the claim.
Important Considerations
| Aspect | Description |
|---|---|
| Reason for Primary Denial | While the bill must be submitted to Medicare after a primary denial, Medicare's decision to pay as secondary is still contingent on its own coverage rules. If the service is not considered medically necessary or a covered benefit under Medicare's standards, Medicare may also deny the claim, irrespective of the primary insurer's decision. |
| Provider's Role | Healthcare providers play a critical role in ensuring claims are submitted correctly and to the appropriate payer (primary first, then secondary). Proper coordination ensures you receive the maximum benefits from both plans. |
| Potential Out-of-Pocket Costs | Even with Medicare acting as a secondary payer, you might still have out-of-pocket expenses. These can include deductibles, coinsurance, or copayments that apply to Medicare, or costs for services that are not covered by either your primary group health plan or Medicare. Understanding these potential costs helps you prepare for financial responsibilities. |
