Question

When a patient is covered by a primary payer plan and a different secondary payer plan:

1) One claim is submitted and the payer transfers claim data to the secondary payer
2) A primary claim is submitted to the primary payer with the remittance advice from the secondary payer as an attachment
3) One claim is submitted and each payer pays half of the charges
4) A primary claim is submitted to the primary payer and a new claim is generated and submitted to the secondary payer

Answer 1

The process of dealing with multiple payer plans involves submitting a primary claim to the primary payer, then submitting a secondary claim to the secondary payer. The primary claim includes a remittance advice from the primary to the secondary payer. Understanding different financing systems and the role of deductibles, copayments, and coinsurance is also crucial.

Step-by-step explanation:

When a patient is covered by a primary payer plan and a different secondary payer plan, the typical process involves submitting the claim first to the primary payer. Once the primary payer has processed the claim and provided payment as well as a remittance advice (which details what has been paid and any patient responsibility), a secondary claim is generated, including the remittance advice from the primary payer. This secondary claim is then submitted to the secondary payer plan, which will determine the remaining benefits and make any additional payments up to the limits of its coverage. This process ensures that the coordination of benefits is managed properly and the patient's coverage is maximized.

It is also critical to understand the differences in health financing systems, such as fee-for-service and HMOs, and how they can impact insurance markets through phenomena like adverse selection. Additionally, it is important to consider the role of deductibles, copayments, and coinsurance in reducing moral hazard and influencing the costs borne by the insured party.