Secondary Coverage

[INS123]

What is the name of your state (only U.S. law)? Ohio


I may have the opportunity to enroll onto my wife's insurance policy, this policy has 90/10 coverage and a $100 deductable, and she pays the family rate already because she has our daughter on her policy, since due to the birthday rule she would be primary. My policy has a higher deductable ($2000) but my employer shares the cost of that, after I pay the 1st $1000 they pay the rest. I do not pay anything for my insurance (except the deductable).

Once the deductable has been met, the plan is really good and pays 100%. I would like to add her coverage so that the $1000 I have to pay is covered by the secondary, but once that is met how would the secondary insurance know that they employer is paying the rest of the deductable? Would the stop the coverage at that time? I wouldn't need the secondary coverage after the deductable has been met, but I doubt that I can just choose when to start and stop benefits during the year.

Since I could be reimbursed from the employer, and the secondary pays minus the 10% and $20 copay, I would essentially be "over paid" would that be illegal or insurance fraud?What is the name of your state (only U.S. law)?

[momm2500]

do you have to supply documentation to your employer that you have paid the $2000 deductible? if so and you do not show them that the secondary insurance picked up the deductible then that can be grounds for termination of employment. for example you have a hospital bill for yourself for $5000. your insurance pays $3000 and then your wifes plan picks up the $2000; why would you want to go after your employer for the $1000 when it was paid by the secondary insurance? this is not a profit making business for you and as indicated can be grounds to terminate your employment. Do you want to risk that? now if the claim is for wife or daughter, your employer might be able to reimburse you the 1000. you should talk to them about what you want to do and see what their procedures are when there are 2 insurances involved.

[ecmst12]

HOW does your employer share the cost?

No, you can't stop and start benefits during the year.

Your plan will pay first and the secondary will pick up excess. If there is no excess, the secondary pays nothing. If the primary and secondary pay, and you still try to submit to your employer for reimbursement, that is indeed fraud and you shouldn't do it.

[cbg]

I'll tell you how the secondary coverage will know.

When a claims office sees that you are submitting a claim on your wife's insurance, they will ask if you are covered under your own policy. If you say yes, they will ask for a copy of the EOB from your policy before they make payment.

If you say no, you are committing fraud. And you would never commit fraud, would you?

[INS123]

Originally Posted by momm2500

do you have to supply documentation to your employer that you have paid the $2000 deductible? if so and you do not show them that the secondary insurance picked up the deductible then that can be grounds for termination of employment. for example you have a hospital bill for yourself for $5000. your insurance pays $3000 and then your wifes plan picks up the $2000; why would you want to go after your employer for the $1000 when it was paid by the secondary insurance? this is not a profit making business for you and as indicated can be grounds to terminate your employment. Do you want to risk that? now if the claim is for wife or daughter, your employer might be able to reimburse you the 1000. you should talk to them about what you want to do and see what their procedures are when there are 2 insurances involved.

No I dont have to show that I paid. I go to the doctors, then pay the bill when it comes after being processed with the insurance and is applied to my deductable. I get the eob from the insurance saying that the charge went to the deductable and is my responsability. I turn that eob into the employeer (actually to a company that takes care of all our insurance stuff), they keep track of the amounts, after I pay my $1000, I keep paying the next $1000 but I send thoes eob's in too, and get reimbursed for the $1000. For your exaple.. if i had a $5000 hospital bill I would pay the 1st $2000 and get reimbursed for $1000 of it, then my deductable would be met and the secondary wouldnt have anything to pay cause my insurance will start to pay at 100% so they would be paying the $3000. I was just trying to see if the secondary would pay that 1st $1000... but then would I just tell the doctors office not to send to the secondary, since I would be reimbursed from my employer?..... I couldnt stop my policy cause then the next year I wouldnt have the benefit....

[INS123]

Originally Posted by cbg

I'll tell you how the secondary coverage will know.

When a claims office sees that you are submitting a claim on your wife's insurance, they will ask if you are covered under your own policy. If you say yes, they will ask for a copy of the EOB from your policy before they make payment.

If you say no, you are committing fraud. And you would never commit fraud, would you?

The claim goes to the primary (mine) and then the doctors office sends the eob and a claim to the secondary. All the secondary sees at that the charges were applied to the deductable, so they pay the doctor.... Does the secondary then send something back to the primary showing that they paid? At then even if they do, are they concerned who pays the deductable... whether its the patient or the secondary insurance.
I'm not trying to do anything wrong, I just want to know how all of this works.

[momm2500]

no the secondary insurance does not notify your employer or your primary insurance. if you take a copy of the eob to your employer and then submit it to the secondary or the doctor does and you get money from your employer.....be prepared for the pink slip. that is FRAUD.

ok and yes you supply something to your employer which is an eob.

Just keep this in the back of your mind:


What is Insurance Fraud?
Fraud occurs when someone knowingly lies to obtain some benefit or advantage to which they are not otherwise entitled or someone knowingly denies some benefit that is due and to which someone is entitled. Depending on the specific issues involved, an alleged wrongful act may be handled as an administrative action by the Department or the Fraud Division may handle it as a criminal matter.