In a situation where a Medicare patient is employed by a small business with fewer than 15 employees, which insurance is primary for services?

In the scenario presented, where a Medicare patient is employed by a small business with fewer than 15 employees, the Employee Group Plan is typically considered the primary payer for services. This is due to the fact that Medicare serves as a secondary payer in such situations.

When an individual is covered by both Medicare and an employer group health plan, the primary payer status is determined by the size of the employer group. For businesses with fewer than 20 employees, Medicare generally pays second. Therefore, when the insurance from the employer (the Employee Group Plan) is in place, it is responsible for covering services before Medicare contributes to the costs.

This arrangement exists to ensure that employers with smaller workforces fulfill their obligation to provide health coverage before Medicare steps in to cover additional costs. Understanding this distinction is crucial for navigating the complexities of healthcare revenue cycles, especially when dealing with Medicare beneficiaries who also have access to other forms of insurance.