Medicare secondary billing for PT practices: who pays first, crossover, and the secondary claim

Medicare pays first. Always. Whatever else the patient is carrying — a supplement, a Medigap plan from a carrier you have no contract with, a retiree plan — it pays second, and it pays based on what Medicare left behind. The only time that order flips is when the patient does not actually have Original Medicare anymore, which is the Medicare Advantage case, and that is a different payer entirely.

That one rule answers most of the secondary-billing questions a PT practice runs into. The rest of this article is the mechanics: what a supplement is, why "we are not contracted with that carrier" does not make the patient out-of-network, how the secondary claim gets to the supplement, and what to do when it does not get there on its own.

The version of this that came up recently

A practice owner in a Facebook group for cash-based practices that bill Medicare was about to send their first Medicare claims and asked:

"Just about ready to submit claims for medicare as primary; question came up re: medicare supplement as primary. can we see them as out of network or not able to see them?"

Both halves of the question have the same answer. A supplement cannot be primary, and not having a contract with the supplement's carrier does not make the patient out-of-network. It is a common question, and it comes up in the same two forms every time: a practice wants to know if it can bill the supplement instead of Medicare, or it sees a carrier name it has no contract with and assumes that means out-of-network.

The payment order, and why it never changes

A Medigap policy is defined by its relationship to Original Medicare. The patient has Part B. You bill Medicare. Medicare determines the approved amount, pays its share, and issues a remittance showing what it allowed, what it paid, and what remains as patient responsibility. Only then does the supplement have something to pay, because what it owes is calculated from what Medicare left over.

This is why a supplement cannot go first. Until Medicare adjudicates, there is no number for the supplement to act on. Sending it a claim before Medicare has processed one does not produce an early payment; it produces a denial.

"We are not contracted with that carrier" is the wrong frame

This is where most of the confusion lives. A practice looks at a supplement card, sees AARP UnitedHealthcare, notices it has no UnitedHealthcare contract, and concludes the patient is out-of-network.

That is not how a supplement works. You generally would not treat the supplement as out-of-network just because you do not have a contract with the carrier. Even when the card says UnitedHealthcare and you have never signed anything with UnitedHealthcare, the supplement still sits behind Medicare and pays based on what Medicare leaves over. Standardized Medigap plans do not have provider networks. What governs the payment is your relationship with Medicare — whether you are a participating provider, a non-participating provider, or have opted out — not your relationship with the company that issued the supplement.

Supplement or Advantage? The distinction that causes the question

Many practices who ask about supplements are actually holding a Medicare Advantage card, and the two work in opposite ways. Getting them backwards is the single most expensive mix-up in Medicare billing for PT. The owner in the thread above corrected themselves a few comments in: they meant Medicare Advantage as primary, which changes everything.

• Medicare Supplement (Medigap): the patient still has Original Medicare. You bill Medicare first. The supplement pays second. No network. Your Medicare enrollment status is what matters.
• Medicare Advantage (Part C): the private plan replacesOriginal Medicare as the payer. You bill the plan, not Medicare. Networks, contracts, authorizations, and fee schedules all apply — and if you are not contracted, the patient genuinely is out-of-network.

The card tells you less than you would like. Patients keep their red-white-blue Medicare card in their wallet whether or not Original Medicare is still their payer, which is how the Medicare Advantage card trap works. An eligibility check before the first visit is what separates the two cases reliably.

Crossover: when the secondary claim sends itself

Once Medicare processes the primary claim, the secondary claim can reach the supplement one of two ways.

If coordination of benefits is on file — the patient's Medigap policy is registered with Medicare's Benefits Coordination & Recovery Center — Medicare will usually forward the claim to the supplement automatically. This is crossover. When it works, you do nothing: the supplement receives the claim, pays its share, and you see two payments for one visit.

In practice, crossover is pretty hit or miss. The policy may never have been registered. The patient may have switched supplements without the update reaching Medicare. The remittance may say the claim was forwarded when nothing arrives. Treating crossover as reliable is how practices end up with a pile of visits where the 20% was never collected from anyone — not written off deliberately, just quietly never billed.

So it is worth having that secondary claim process figured out, because you will need it.

Building the secondary claim yourself

When crossover does not happen, you submit to the supplement directly, and the Medicare remittance is what you build the claim from. The supplement is not recalculating the visit; it is paying against Medicare's determination, so the secondary claim has to carry that determination with it: the Medicare-allowed amount, what Medicare paid, the adjustment reasons, and the remaining patient responsibility.

A concrete version. You see a Medicare patient for an evaluation. Medicare's approved amount for the visit is $100. Medicare pays 80%, or $80, and leaves $20 of coinsurance. If the patient has a Plan G supplement, that $20 is what the supplement owes. You do not bill the patient for it and you do not write it off — you bill the supplement, using Medicare's remittance as the basis, and collect the full $100 across two payers.

Which supplement the patient holds changes what is left over. Plan G covers the Part B coinsurance and Part B excess charges but not the annual Part B deductible, so early in the year the deductible falls to the patient. Plan F covered the deductible too, but it is closed to anyone who became eligible for Medicare on or after January 1, 2020, so you will see it only on longer-standing patients. Plan N covers the coinsurance but leaves small copays at the point of service. Read the plan letter before you assume the balance is fully covered.

The short version

• Medicare pays first, always. A Medicare Supplement cannot be primary.
• Not being contracted with the supplement's carrier does not make the patient out-of-network. Standardized Medigap plans have no network; Medicare SELECT is the exception.
• If it is a Medicare Advantageplan rather than a supplement, everything above reverses — the plan is the payer, and the network is real.
• Crossover forwards the secondary claim automatically when coordination of benefits is on file, and it fails often enough that you need your own process.
• When it fails, build the secondary from the Medicare remittance and send it to the supplement yourself.