Question: I received a call from my doctor’s office. My Medicare claim for the appointment I recently had was denied. Medicare says I have other insurance. I don’t think I do. What should I do?

Answer: The phone call you received is probably a Coordination of Benefits (COB) issue. Coordination of Benefits is how the insurance companies keep track of who pays first and who pays second. Many of us have changes to our insurance situation over the years.

Sometimes this COB issue pops up without reason. Sometimes this COB is due to a recent change in our insurance.

I will use an example of how COB can work and change; I recently had a client (Sally) who had an employee plan through her employer. This Plan also covered her husband. Her husband (Bob) turned 65 and was therefore eligible for Medicare. Medicare would be secondary in this situation (because her employer group was more than 20 employees). So he signed up for Medicare A only. Prior to his 65th birthday they received a form asking about his Medicare coverage. That form was completed showing his Medicare Part A coverage only.

Their situation changed when Sally retired. Sally had accrued sick time, which paid the premium for the insurance even after she retired. Now that Sally was NO longer working, Bob needed to sign up for Medicare Part B. This change in status changed the ORDER of the insurance. Medicare becomes primary and the Employee (now retiree) Coverage becomes secondary. This is the “Coordination of Benefits”.

So a NEW COB form was completed indicating the Medicare A & B were primary and the Employee/Retiree Plan was secondary. This form usually comes from Center for Medicare & Medicaid Services (CMS). This form is usually red print with a fill in the box type format. You also may receive these forms from the insurance companies that you are using in addition to Medicare.

There are also COB issues when nothing appears to have changed. An example of that is when Medicare discovers that you were in an automobile accident in the past and the recent treatment you had could/should be covered by Auto Insurance. You could have two insurance companies covering you, like Medicare and an Employee plan. You could also have a worker’s compensation/injury case that is covering part of your medical care and your employee insurance covering the rest. These are all examples of when COB comes into play.

Those COB forms are the insurance industries way of keeping all the claims and payment for claims up to date. That is one of the reasons that most times now when you go to see a provider they ask you to verify your insurance coverage. It prevents that situation I just explained from happening. We sometimes forget to tell insurance companies and providers about our different/new insurance coverage.

In the situation you appear to be in, there is some confusion about who is the primary payer of your medical claims. There is a Medicare Coordination of Benefits Department. Their contact information is 1-855-798-2627. The COB Call Center can help you determine if there is a problem, what the problem is, & how to resolve it. Be prepared, it is a system where you have to listen to the options and press the appropriate number. This COB Call Center can handle problems related to Medicare Part A (hospitalization coverage), Medicare Part B (outpatient care) or Part D (prescription drug coverage).

This number is NOT a number to be used to review ‘how’ Medicare covers a procedure or diagnosis, but instead WHO pays first, Medicare or another insurance product.

When dealing with a COB issue I also want to stress your need for patience. When there is a problem with Medicare and COB with other insurance products, it takes a number of days for ‘the system’ to get the records updated. That information then needs to be re-processed (rebilled) by all the providers you have seen. The providers cannot rebill immediately after you have called to correct the COB issue.

In the meantime you may continue to get notifications in the mail that claims have been denied. Some of this has to do with the delay in getting your mail. When working through these issues, I tell people it sometimes takes months to get all of the claims corrected and getting the mail for those claims.

To give an example; when you visit your doctor on May 7th, it is billed to Medicare and any other insurance products you may have. That claim may not be billed to Medicare or your insurance companies on the 7th. The office may do all their billing on Thursday (May10th). The computers process the claim. The doctor’s office is notified pretty quickly via the computer, but you won’t get the notice from Medicare for months.

Medicare mails out claims processed by them on a quarterly basis. That means your May billing is processed in May, but is not mailed to you until the beginning of July (quarterly billing –April/May/June). The quarterly packet you get in July you may see the incorrect/denied claims and the corrected claims.

Now imagine you see a number of physicians, or have multiple tests within that week of May 7th. You can see how it compounds the paperwork.

In this way it seems like this problem drags out for months, and it can. It is usually correct within two weeks of discovery, but it takes months for the paperwork to show that correction.

Earlier in this article and in past articles I have touched on the COB forms that need to be completed when your insurance changes. It does not always need to be completed by you, many times our insurance coverage changes without incident. If you get some of these COB forms in the mail, I do recommend completing them and returning them.

If you receive forms to complete and you do not understand them or do not understand why you have to complete them, call the company that sent them and ask what they are and why you have to complete them.

Realize that this paper trail helps to keep the correct company paying the claim. As I briefly illustrated in the beginning, sometimes Medicare is Primary coverage and sometimes it is secondary coverage. This usually has to do with the size of the employer group and whether you are working or retired from the company that is providing the insurance.

Please remember that once you have these forms completed, you should always make a copy to keep for your records, so you know have proof that you did it and what you told them. These forms can seem unnecessary, but it is better to fill them out, than later having the hassles of COB problems.

Again, if you have questions or concerns relating to claims being denied due to other insurance coverage, (Coordination of Benefits), call 1-855-798-2627.

If you have general questions regarding Medicare coverage you can always call the 1-800-medicare (633-4227) phone number.

To contact Janell Sluga, GCMC with insurance questions or concerns, please call 716-720-9797 or e-mail her at janells@lutheran-jamestown.org.