By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
November 20, 2024
Yes, it exists, and it's quite important in the healthcare system.
What is it? Why should you care? Are there helpful tips? Let's explore.
A. The Birthday Rule rules
1. Once a new child is added to your household (a new baby, a foster, adopted or step-child) and both parents have their own health policy, it is imperative to determine which carrier/plan is primary and pays first, and which comes next. The birthday rule helps make that determination.
2. This rule does not apply to Medicare (for seniors or handicapped adults) or Medicaid (always comes last)
3. How does it work:
· In general, the parent whose month of birth comes first in the year gets primary coverage for the child, not the year, but the month. And if the month is the same, then the day within that month. If the month and day of birth is the same for both parents, then the coverage that became effective the earliest becomes primary.
· The primary payer usually covers the largest share of the claim, then the secondary payer covers some or the rest of the remaining liability.
· A claim is submitted to the primary insurance, which issues an EOB with a patient liability. The claim is then sent to the secondary which processes that patient liability and based on their own terms of coverage. That 2ndary EOB will determine the patient’s final cost.
· There are exceptions: in case of divorce or separation, the parent who has the custody becomes primary coverage, or as determined by the final Court order. If one of a plan is under Cobra, meaning the coverage has termed because the employment has termed, but the parent continues paying coverage out of their own pocket for 18 or up to 36 months, then the COBRA coverage becomes secondary to any other plan with a currently employed parent.
B. What to know
1. Payments will depend on the right order. Billing in wrong order will result in 2 denials, and a denial means you get billed.
2. The order is NOT your choice nor decision. They are very strict rules, laws and mandates that force insurance companies to declare themselves primary or secondary.
3. You cannot double dip either. That is to ensure that your insurance companies pay their fair share but do not pay twice. You might receive a routine “coordination of benefit” questionnaire from your plan, but if you don't get one, but you know you have a different health insurance or additional for your child, it must be reported to any and every insurance plan your child is covered under.
4. Each plan's terms of coverage apply even if a primary plan covers a service or an item, but the secondary does not, for example. The secondary is not forced to cover what the primary does.
5. The share of cost or your out of pocket max - the liability you must meet - for each plan does not overlap from one plan to another, so your child may well have met his or her own deductible or co insurance amount with one plan, but not with another.
C. Tips
1. Is dual coverage worth it? It depends!
· If the either plan has a high deductible / out of pocket max and will likely never issue a payment: maybe consider dropping it especially if you pay the premiums or part of the premiums.
· If a HSA or HRA account is attached to one of the plans, and your employer gives you “free” money to cover medical expenses, keeping it makes sense.
· If one plan offers better benefits, keeping both may not make financial sense if the premiums you pay are higher than reimbursements.
· What if the medical provider networks do not overlap, or if your doctor only belongs to one meaning the other coverage will likely never issue a payment? Check on out of network benefits and especially the max share of cost. You might be paying premiums for nothing or not much.
2. The good thing is one bill can count twice. Let's take an example. Let's say the primary has applied $750 towards your deductible, but the secondary's deductible is only $500. The secondary will then pay $250 leaving you with a deductible of $ 500.00 not $ 750.00 but the good thing is, you actually get credited $1,250 ($750 to the primary $500 to the secondary insurance) but you only paid $500
3. Consider removing the dependent but keeping the plan. Yes, you can drop a dependent from a plan without other family members being affected.
Conclusion: Avoiding delayed or denied claims is an easy step away: contact each insurance carriers to report another coverage. Insurance companies will talk it out, and issue an official “order of pay”. Once the medical providers are made aware of this order, there should be no issue regarding this matter.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024™
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