Personal Finance

Coordination of Benefits

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  • Feb 23rd, 2010 12:07 pm
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[OP]
Member
Feb 11, 2009
291 posts
10 upvotes

Coordination of Benefits

Coordination of Benefits

Both my wife and I have benefits through our employers. She has a Flex plan which offers her $800/year in any kind of benefits (dental, vision care, etc.). I have a much more robust plan which provides set amounts in each kind of benefit.

My concerns are with the coordination of benefits. Ideally, we'd like her to use my benefits first, and then use her plan to cover the costs which aren't covered by my plan (for instance, mine covers 85% for dental).

I understand that, according to the Canadian Life and Health Insurance Association, employees are supposed to first make their claim to their own plan, and then make the claim to their spouse's:

"Coordination of benefits will work properly if plan members understand which insurance plan to submit their claims to first. In the case of claims for the plan member, the industry guidelines establish the plan member's group benefits plan as the first payer, the dependant coverage available through his or her spouse's plan as the second payer, and then any Health Care Spending Account coverage as the third payer. If the plan member and his or her spouse both have insurance company drug cards, pharmacists can coordinate claims payments for both plans right at the pharmacy drug counter."

Both plans are held by different companies, and my insurance company does not know that she has a plan since her employer has only recently provided her with coverage. Is there any problem with claiming her benefits under my plan first, and then going to her plan? Will her provider notice that she didn't go to them first and require a resettlement?

Thanks for your help!
5 replies
Deal Addict
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Apr 14, 2005
1653 posts
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Just making up some numbers here. I think what your proposing to do is have your wife make a claim under your plan, let's say get 75% reimbursement. Then go to her own plan and get 75% reimbursement again. Then go to her spending account and get the other 25%. i.e. collect 175% reimbursement.

You know this is wrong, right? It is called fraud. Yes, they have checks in place to prevent it. But, yes, you might get away with it.

Whenever I make a claim on my wife's plan or vice-versa they ask for evidence of what was paid out by the other provider first. Without this, the claim is denied. It is a hassle. Not sure how/when one provider became aware of the other but there is no way, between the two of them, for me to commit this same fraud.
Jr. Member
Dec 4, 2009
121 posts
7 upvotes
Calgary,AB
ddhx wrote:
Feb 23rd, 2010 9:30 am
Coordination of Benefits

Both my wife and I have benefits through our employers. She has a Flex plan** which offers her $800/year in any kind of benefits (dental, vision care, etc.). I have a much more robust plan which provides set amounts in each kind of benefit.

My concerns are with the coordination of benefits. Ideally, we'd like her to use my benefits first, and then use her plan to cover the costs which aren't covered by my plan (for instance, mine covers 85% for dental).

I understand that, according to the Canadian Life and Health Insurance Association, employees are supposed to first make their claim to their own plan, and then make the claim to their spouse's:

"Coordination of benefits will work properly if plan members understand which insurance plan to submit their claims to first. In the case of claims for the plan member, the industry guidelines establish the plan member's group benefits plan as the first payer, the dependant coverage available through his or her spouse's plan as the second payer, and then any Health Care Spending Account coverage as the third payer. If the plan member and his or her spouse both have insurance company drug cards, pharmacists can coordinate claims payments for both plans right at the pharmacy drug counter."

Both plans are held by different companies, and my insurance company does not know that she has a plan since her employer has only recently provided her with coverage. Is there any problem with claiming her benefits under my plan first, and then going to her plan? Will her provider notice that she didn't go to them first and require a resettlement?

Thanks for your help!
Both plans are held by different companies, and my insurance company does not know that she has a plan since her employer has only recently provided her with coverage. Is there any problem with claiming her benefits under my plan first,
>> On the insurance form, you will have to answer YES or NO, if you have another insurance company...

and then going to her plan? Will her provider notice that she didn't go to them first and require a resettlement?

>> YES, because your insurance will issue an "explanation of benefits", after you submitted the claim form...then you will have to mail this paper to 2nd insurer to claim the difference amount...the 2nd insurer will notice that your spouse is listed as a Dependent on your policy and she is the main policy holder on hers.....


ps: Usually on Dental & Drugs (& Life insurance too) - insurance company shared a database, that's why when you visit a dental office or pharmacy you pay "Your Contribution amount" or "Your Copayment"...The insurer will enter your info in the shared database and others can access it.

** The flex plan ($800/yr) you mentioned above, If I understand it should be a HealthCare Spending Account (HCSA). if YES, use your Policy first, then claimed all copays in the HCSA (it should be fine)
[OP]
Member
Feb 11, 2009
291 posts
10 upvotes
mork wrote:
Feb 23rd, 2010 10:45 am
Just making up some numbers here. I think what your proposing to do is have your wife make a claim under your plan, let's say get 75% reimbursement. Then go to her own plan and get 75% reimbursement again. Then go to her spending account and get the other 25%. i.e. collect 175% reimbursement.

You know this is wrong, right? It is called fraud. Yes, they have checks in place to prevent it. But, yes, you might get away with it.

Whenever I make a claim on my wife's plan or vice-versa they ask for evidence of what was paid out by the other provider first. Without this, the claim is denied. It is a hassle. Not sure how/when one provider became aware of the other but there is no way, between the two of them, for me to commit this same fraud.
No, like I said in my message, after having my insurance cover the 85%, I would get the balance paid off by her company; hence, the coordination of benefits, not fraudently collecting them twice.
[OP]
Member
Feb 11, 2009
291 posts
10 upvotes
My question centered on whether it is possible to reverse the order in which we file our claims so as to maximize our benefits. But the answer looks to be no.
Deal Addict
User avatar
Apr 14, 2005
1653 posts
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ddhx wrote:
Feb 23rd, 2010 11:50 am
No, like I said in my message, after having my insurance cover the 85%, I would get the balance paid off by her company; hence, the coordination of benefits, not fraudently collecting them twice.
Oh, sorry. That definitely won't work, but the fraud approach I described has a chance. Once you tip off each insurer of the others existence, you'll need to play by the rules. Like I said, I find we have to jump through a lot of hoops to have our claims go through.

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