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Wednesday, August 17, 2011

Other Payers on a Medicare Patient

There are specific guidelines we all must know and follow as we see Medicare patients that have another primary payer other than Medicare. (e.g., Workers Comp., Auto Insurance, Personal Injury, etc.)  Keep in mind, we are required to bill Medicare for ALL covered services even if there is another payer.

As a Participating Provider, you may bill your normal PI fees on this Medicare patient to all other payers and collect above the Medicare fees from other payers. 

Non-participating Providers, even though they receive the highest reimbursement from Medicare (i.e. the limiting charge), you must NEVER bill or collect from any payer on this Medicare patient above the limiting charge. (The limiting charge is the amount your Medicare carrier has set for your local.)  Item 10a through 10c on the claim form or in the electronic billing format will tell the Medicare Carrier (and other payers) who is responsible for payment.

Make a copy of the claim to the primary payer other than Medicare e.g., Workers Comp., Auto Insurance, Personal Injury, etc., and also, send a copy of the claim to the Medicare Carrier.  Be sure when billing another payer on this Medicare patient, to have the patient sign an ABN each visit, for both covered and non-covered services and use all modifiers, since Medicare will not pay.  (Example:  98941 AT GA)

The advantage of billing Medicare on this PI claim is if the PI claim fails and your patient loses the case, now Medicare will pay most of the claim because it was billed within the year time limit with all the correct modifiers and fees.

Questions? Give me a call today at 1-800-MY CHIRO.

Dr. Street


  1. Every healthcare provider should switch to an EMR solution. Paper based records and prescriptions are a thing of the past now and it would be best for both doctors and patients to take advantage of their features and accessibility.

    Medical Billing

    1. Thanks for the comment! Electronic records are the best, you are right. However, Personal Injury (such as car accident, or work comp) cases still are required to be paper claims.


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