2. Official Disclaimer
The information presented is for general information only and is not
meant to substitute for legal advice. Always seek the advice of an
attorney on legal matters.
The presenter makes no recommendations as to an individual
physician’s participation or non-participation with any specific health
plans, insurance company or payer. Each physician is urged to give due
and proper consideration to their individual practice needs and act
independently regardless of the actions or non-action of other
physicians.
Legal Guidance
Copyrighted © Material is subject to fine of $5000 per occurrence
02

3. 03
 Denials related to coordination of
benefits are among the leading reasons
for a claim to be denied.
 It means that the payer has evidence of
other coverage, or reason to believe that
there is other coverage that should be
primary.
 The payer may be right or wrong.
Denied – Other Insurance Primary

4. 04
Coordination of Benefits
When the patient is covered by more than one health benefit plan, a structure is needed to determine
which insurance carrier is the first – primarily responsible for the bill – and which is second.

5. 05
Determining Who Is Primary
• Commercial
• Each patient is primary for themselves.
• Children according to the birthday rule (the parent whose birthdate falls first in the year is primary).
• Divorced parents – Court order – When doubtful, the parent who has custody is primary.
• Medicare/Commercial
• Commercial Primary
• Employer groups over 20
• Medicare Primary
• Employer groups under 20
• ESRDMedicare Disability
• Other Third Parties – based on the event
• Workers’ compensation
• No-Fault
• Homeowners
• Victim Compensation Board

6. 06
If a Physician Is Par with Both Plans
• Primary Plan pays the claim up to the
lower of the allowable rate or the
physician’s charge
• Secondary Plan pays the remaining
portion of the bill after the primary
carrier has made its payment
• This includes payment toward services
not covered by the primary plan

7. 07
If a Physician Is Not Par with Both Plans
Who is primary and who is secondary does not matter. The patient is responsible for paying the bill to
the physician and then seeking whatever coverage is available directly from their insurance plan(s).

8. 08
But What If the Physician Is Par in One and Not the Other?
• No obligation to bill the primary
carrier.
• If bill is primary:
• Pay to patient - chase
payment
• Pay to physician - send to
secondary for balance
• Denied – send to
secondary
• Physician’s maximum
reimbursement is the allowable of
the secondary.
Physician non-par with
primary – Par with the
secondary
• Physician’s maximum
reimbursement is the allowable of
the primary
• Collect any remaining balance from
the patient and let them seek
payment from the secondary carrier.
Physician Non-par with
secondary

9. 09
Protection Against COB Denials Is Accuracy at the Time of
Registration
• It is the patient’s responsibility to disclose all insurances
• Check-in documentation should require the patient to disclose ALL other insurances.
• Trust – but verify
• Eligibility (while not guaranteed) should be verified with each payer at the time of services.
• It is even better to check eligibility at the time of scheduling
• PMS systems automatic verification
• Pheerisa or any commercial verification service

10. 10
Bolster Accurate Patient Disclosures with This Declaration
Be advised of New York State law: NY Penal Code Section 176.05
A fraudulent health care insurance act is committed by any person who, knowingly and with intent to defraud,
presents, … a claim for payment, services or other benefit pursuant to such policy, contract or plan, which
he knows to:
(a) contain materially false information concerning any material fact thereto; or
(b) conceal, for the purpose of misleading, information concerning any fact material thereto . . .
The providing false, inaccurate or incomplete information as to your insurance coverage has been and could
be construed as a fraudulent act the New York State Insurance Department, Fraud Bureau, in accordance
with the above.
Such acts are also subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each
violation.
It is the policy of this practice to report to the NYS Insurance Fraud Bureau all cases of suspicion of
insurance fraud.

11. 11
Nothing reduces the risk of bad information about coverage than
credit card authorizations
Require credit cards for all patient visits

12. 12
COB – Coordination of Benefits
• There is an obligation to cooperate with reasonable requests to
assist with COB rebilling –often a contractual obligation
• Commercial
• generally up to 1 year
• Medicare
• up to 15 months after the close of the Federal fiscal
year
• Payer must provide sufficient information to re-bill without
an inordinate research

13. 13
WARNING:
Never let a patient self-select their responsible party.
You will be held to the regulations, not their wishes.

14. 14
Responding to Recovery Demands Based on “Other Insurance Primary”
NEVER, NEVER, NEVER, NEVER….
Send a recovery payment to a plan BEFORE you are paid by the other carrier
Immediately bill the “Other Carrier”
• If you don’t get paid – you owe nothing
• If you get a denial – send the denial
• If they don’t send you a reasonable request – send it back
Immediately advise the patient
If the payer is pressing you for the payment, write to them:
• “We have billed the other carrier based upon your representation. On receipt of a response from
that carrier, we will make any adjustment due to your company. This practice does not consent to
an off-set of your alleged claim prior to determination of any responsibility.”

15. 15
Why Do Plans Press COB
Health Plans can reduce
the cost of medical
care by some $0.70-$1.00 pmpm

16. 16
Complete Intolerance in COB
Dear Patient:
Your insurer, ___________ has advised this office that you failed to provide complete, accurate and proper insurance coverage information at the time of services. Specifically ________ alleges that you
failed to disclose to us that you had other insurance, which would have been responsible for these charges.
_______ is now demanding that this office refund the money that it paid us for the services that we provided to you.
We would have preferred to bill that other insurance carrier, and allow them to accept responsibility for this claim. However, _______ is demanding a refund at this time, and not providing us an
opportunity to assure that the other insurer will accept responsibility.
We are not in a position to dispute ________ allegation of your failure to properly disclose your other insurance coverage.
Please be advised of NY Penal Code, Section 176.05
A fraudulent health care insurance act is committed by any person who, knowingly and with intent to defraud, presents, … a claim for payment, services or other benefit pursuant to such policy, contract or
plan, which he knows to: (a) contain materially false information concerning any material fact thereto; or (b) conceal, for the purpose of misleading, information concerning any fact material thereto .
. .
The failure to provide complete and accurate information as to other insurance at the time services were provided could be construed by the New York State Insurance Department, Fraud Bureau, in
accordance with the above.
Such acts are also subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each violation.
This office can not determine if the omission of accurate insurance coverage information was intentional or not, such is the responsibility of a court of appropriate jurisdiction or other regulatory agency.
Therefore, should you not make payment of this claim in full to this office within the next 15 days, the attached suspected fraud Report will be forwarded to the New York State Insurance Department, Fraud
Bureau.
You may also include complete information as to your other insurance, and we will seek payment as well from that other insurance. If we receive reimbursement from that insurance, we will refund the
amount do you.
Questions regarding _________allegation of your non-disclosure of other insurance should be made to __________at the phone number on the back of your identification card.
Sincerely, Enclosure – Fraud Bureau report

17. 17
Failure to Disclose Insurance Coverage

18. 18
COB Is Becoming Less Common
• As health premiums increase, employers are increasing payroll deductions for family coverage.
Therefore, a family with two wage earners, eligible for two health benefit plans, has dropping
overlapping coverage.
• Some employers are providing an economic incentive to drop family coverage if eligible.