Written by Leah Arundel, knower of all things insurance
Duncan Lake Speech Therapy, LLC
Insurance is a confusing world. When it comes to primary vs. secondary insurance, though, does it really matter to know the difference between the two?
Answer: DEFINITELY!
As a healthcare provider, it is inevitable that we will come across patients that have multiple insurance policies. It is our job to work with our clients to help identify which policy is considered your Primary, therefore making your additional policy your Secondary. Gaining knowledge of this information will be key in making sure each of our client’s therapy sessions will be covered and paid in a timely manner!
What is the difference between the two?!
When pinpointing your Primary insurance we ultimately learn that this policy is where your claims journey to being approved will begin. Duncan Lake will first create your claim and then send it off to be processed according to your insurance plan with this payer. Once they are done processing your claim, it will then be sent back to us and we will review it for accuracy and then send it off again to your secondary insurance company. If allowed, your secondary insurer will then apply any additional payments on this claim and then send it back to Duncan Lake for it to be finalized!
Keep in mind, payment from your secondary insurance is not always guaranteed. This ultimately will depend on the specific insurance company, as well as your specific benefit package. Because of this, performing an eligibility check prior to our patient’s treatment is best practice in understanding what we can expect for each individual client.
Figuring out your Primary from your Secondary
Designating who your Primary insurance plan is done through something called a Coordination of Benefits. A patient or a patient’s guardian can decide which insurance provider they would like to elect as their Primary. If, for any reason, you are unsure of this information, it can be easily figured out by calling each individual insurance company to verify.
In some cases, we run into a situation where a minor or young adult is covered under both of their parents’ plans. In these cases, insurance companies will use what is called the “Birthday Rule” to determine which plan is primary vs secondary.
The Birthday Rule
The birthday rule comes into play when a child is covered under both of their parent’s plans. Whichever parent’s birthday falls first in the year will be the child’s Primary insurance while the other parents insurance will provide coverage as Secondary. — If, by chance, both parents share the same birthday, the Primary plan will be determined by whichever policy has the earliest effective date.
Cases in which parents are divorced, the birthday rule will still determine what coverage is Primary vs. Secondary for the child, unless there is a county order.
Now let’s say you are an individual covered under COBRA, COBRA will always fall under Secondary.
Lastly, let’s say you happen to be married but you’re still under the age of 26! You will be covered under the plan with the earliest effective day as Primary. However (LOL), if you happen to have coverage though your employer, this will automatically become your Primary over any scenario.
But what if I have additional insurance plans?!
It’s fairly common for a patient of ours to come in with a Secondary insurance plan. This is because we often have kids come in and both parents have their individual insurance plans (usually through their employers). We also run into this when individuals have supplemental plans such as Medicaid and Medicare. HOWEVER, there’s more…Tertiary and Quarterly plans! Although it’s not as common, there are times when a patient has additional policies that they are under. As crazy as that might be for our biller, all of these policies will still follow the same rules stated above as well as the claims submission process.
Coordination of Benefits MATTERS!
Having a proper understanding of Coordination of Benefits is the most crucial step when dealing with multiple plans. Our office will do our duty in performing Eligibility and Benefits checks with each of your insurers and in making sure this information is documented correctly within our EHR.
If there happens to be any claim issues when billing Secondary insurance, the solution usually lies in having an inaccurate understanding of your Coordination of Benefits. This may even just be a mistake between you and your insurance provider in not knowing that your Primary or Secondary insurance is no longer active. In this case, we would have you call your active policy and update your Coordination of Benefits so that your claims can be processed correctly. So, although this may seem time-consuming and tedious, it is not impossible! Besides, at the end of the day, we will do anything for our Duncan Lake Family and Friends!
Leah Arundel | she/her | Administrative Assistant and Medical Biller
XOXO
