A medical assistant is processing a claim for a patient who has Medicare as their primary insurance and a Medigap plan as their secondary insurance. The Medicare payment summary indicates that Medicare paid 80% of the approved amount, and the patient's deductible has already been met. Which of the following actions should the medical assistant anticipate next regarding the Medigap plan?
- ASubmit a new claim to the Medigap plan for the full original charge.
- BSend the remaining 20% balance directly to the patient for payment.
- CContact the patient to obtain authorization before billing the Medigap plan.
- DThe Medigap plan will automatically be billed for the remaining 20% after Medicare's payment.
Show answer & explanationAnswer & explanation
Correct answer: D. The Medigap plan will automatically be billed for the remaining 20% after Medicare's payment.
Medigap plans (Medicare Supplement Insurance) are designed to cover the 'gaps' in Medicare coverage, such as the 20% coinsurance Medicare doesn't pay. When Medicare is primary and a Medigap plan is secondary, the claim typically 'crosses over' electronically to the Medigap plan for processing of the remaining balance after Medicare's payment, without requiring a separate submission from the provider's office.
Why the other options are wrong
- A. Submitting a new claim for the full original charge is incorrect and inefficient; the Medigap plan only needs to process the remaining balance after Medicare's payment.
- B. Sending the balance directly to the patient bypasses the secondary Medigap insurance, which is designed to cover this portion.
- C. Authorization is generally not required to bill a secondary insurance like Medigap once the primary (Medicare) has processed the claim, as the patient has already consented to its use.
Medicare Crossover Claims (Medigap)
The automatic electronic transmission of a claim from Medicare to a Medigap (Medicare Supplement) plan for secondary payment after Medicare has processed its primary portion of the claim.
- Designed to simplify billing for providers and patients.
- Covers patient cost-sharing (deductibles, coinsurance) left by Medicare.
- Eliminates the need for providers to submit a separate claim to the Medigap plan.
- Requires the Medigap plan information to be on file with Medicare.
Memory trick: Medicare 'CROSSES OVER' the bill, Medigap catches the rest.