Primary Payer at Diagnosis


With Insurance Coverage plans dominating the news cycles, it seems like a good time to brush up from a CTR point of view. (Honestly, I can’t remember when I last looked over this part of FORDS).

Possibly I felt more comfortable than some when faced with coding the Primary Payer at Diagnosis: I come from a long line of insurance people- an insurance agent, an insurance examiner, an accountant for an insurance company. One sister even helped set up health exchanges for the Affordable Care Act. I worked summers in the file room of an insurance company as a student, and then in several hospitals across several states in hospital registration departments helping people pay their co-pays, determine whether they needed pre-authorizations, and whether the service, as ordered, was covered.  

Still, it’s not a slam-dunk.

We are tasked with “identifying the patient’s primary payer/insurance carrier at the time of initial diagnosis and/or treatment. This should be relatively easy, since hospital accrediting bodies require the patient admission page to document the type of insurance of payment that will cover the patient’s hospital care.  Per FORDS:

  • Record the payer at time of diagnosis.
  • If payer at the time of diagnosis is not known, record the payer when the patient is initially admitted for treatment (i.e., don’t code unknown because you don’t have information from a prior facility, etc.).
  • Record the type of insurance reported on the patient’s admission page.
  • If more than one payer or insurance carrier is listed on the patient’s admission page, record the first (this is because the hospital will strive to list the primary insurance carrier first; typically, the second insurance listed takes on a “supplemental role” and will only pay for what is left after the first insurance company is billed. This is true even when, say, a married couple each has insurance through an employer, and both choose a family coverage option; the companies don’t split the bill evenly).
  • If the patient’s payer or insurance carrier changes, do NOT change the initially recorded code (as with so much else in the world of cancer documentation, it’s important to be able to easily reference what happened at the beginning of care).

After taking all that into consideration, the proper code must be chosen, and that can be an unexpected puzzle. There are the government options, and then there are “Fee-for service” and “Managed Care Plans”. These days, the Managed Care Plans seem to vastly outnumber the “Fee for Service” plans (which typically are what used to be called “Major Medical” plans; as the name infers, they offered little coverage for anything but hospitalizations).  

Managed care plans usually offer incentives for patients to make use of regional “networks”; and managed care plans/networks can be set up for employer based plans, Medicaid plans, or Medicare plans.

Medicare has an additional wrinkle: it’s not ALWAYS the primary plan for someone over 65; if the patient is still working, or is covered under a spouse who is still working, Medicare may be SECONDARY to the employer plan. (Look carefully at how it is recorded in the EMR).  

Another wrinkle: When it comes to choosing codes, especially between managed care plans, managed care plans often go by names that give you no clue that they are, in fact, managed care plans. For example, Pacificare/United Health Care is a managed health plan, “Secure Horizons” as the Medicare Managed Care plan.  Another example person might or might not recognize “Gateway” as a Medicaid Managed Care plant gets tricky.

I often run through my own “mini-check list”:

  • If the patient is over 65, even if the name of the plan gives nothing away, I try a quick Google search to determine the true nature of the plan.
  • I check to see if the face sheet in the EMR includes helpful abbreviations, i.e., “Secure Horizons MCR“.
  • And, of course, I check for obvious buzzwords, such as “Senior”, “Golden”, etc.

Single payer, anyone?