Medical Billing Forum

Billing => Billing => Topic started by: Jdmontee on June 30, 2009, 10:06:05 PM

Title: Medicaid billing
Post by: Jdmontee on June 30, 2009, 10:06:05 PM
Need some additional clarification regarding billing Medicaid in the state of Pa.  Have done research regarding state and federal regulations and want to be sure I am understanding them correctly. This is in regards to psych evals (90801) only. If there is a primary insurance in place Medicaid is to be the payor of last resort correct?  Is there anything that I might be missing in regards to this?

Thanks!

Joanne
Title: Re: Medicaid billing
Post by: PMRNC on July 01, 2009, 05:32:57 AM
If they have a primary to Medicaid it most likely is Medicare. If there is a group plan primary, there is something not right  :o
Title: Re: Medicaid billing
Post by: Jdmontee on July 01, 2009, 07:32:00 AM
In the state of Pennsylvania you can have a private individual or group plan of insurance in addition to Medicaid. Most of this provider's patients are children and have special needs and medicaid pays for these evals for determining wrap around and TSS services. What I need to know is if anyone is familiar with PA regs and know if there is anything I am missing in regards to Medicaid being the payor of last resort. If they have a private/group plan in addition to Medicaid does the private ins have to be billed first or is there an exclusion to this that I may not know about.

Thanks.

Joanne
Title: Re: Medicaid billing
Post by: PMRNC on July 01, 2009, 09:02:29 AM
Quote
In the state of Pennsylvania you can have a private individual or group plan of insurance in addition to Medicaid. Most of this provider's patients are children and have special needs and medicaid pays for these evals for determining wrap around and TSS services. What I need to know is if anyone is familiar with PA regs and know if there is anything I am missing in regards to Medicaid being the payor of last resort. If they have a private/group plan in addition to Medicaid does the private ins have to be billed first or is there an exclusion to this that I may not know about.

Yes, you can have Medicaid, under certain circumstances however PA has always had a big problem with their eligibility checks..anyway to answer your question..Medicaid would be the last payor.  You would follow COB rules where group plans are in place. If there is an individual policy however you will want to check with Medicaid, that could be iffy depending on the person paying the premium and circumstances, regardless if you are submitting a private/group plan primary to Medicaid it's always a good idea to let each one know about the other to avoid problems.
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 01, 2009, 12:59:42 PM
Even if its an individual policy, it would be primary regardless of who pays the premiums. The one thing that is true no matter what state you are in, is that Medicaid is ALWAYS the payor of last resort. In NC, once you bill the primary and send the claims to medicaid, they will place a code on the medicaid card, that will alert you of other insurance. The issue in NC is when the client no longer has the policy, and they haven't notified medicaid to update it. You have to get documentation from the insurance company to send to medicaid along with the claim to update and process (grrrr).
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 01, 2009, 01:06:15 PM
Medicaid of PA has a policy whereas they seek providers in helping to recoup money from COB issues where recipients are not giving them information regarding other insurance. Again, this enforces the policy of Medicaid being the last payor.

April 27, 2009 Third Party Liability Recovery

On April 27, 2009, the Department of Public Welfare's (DPW) Division of Third Party Liability (TPL) issued a Commercial TPL/Coordination of Benefits (COB) recoupment project related to claims originally paid by Medical Assistance (MA) through its TPL contractor, Health Management Systems, Inc. (HMS). The April 27 recovery was sent to provider type 01 (inpatient facility).

    * This TPL/COB Recoupment Project encompasses recipients having Commercial coverage.
    * TPL is seeking assistance from medical providers in recouping funds associated with recipients who had both commercial and MA coverage at the time the service was delivered. DPW was not aware of the coverage at the time of service delivery.
    * TPL and its contractor, HMS, are continually identifying resources via eligibility data exchanges with commercial carriers. These are often identified after a claim is paid. It is a Federal requirement that TPL recoup payments when a third party is identified. MA is to be the payer of last resort.
    * The claims in this project cover dates of service associated with Commercial resources (excluding Medicare Advantage plans) from March 2006 through October 2008.
    * The letter to providers related to this recoupment project includes the following: two listings of the claims being considered for recoupment; instructions for responding to the TPL/COB Recoupment Project; and HMS contact information should the provider have questions.
    * The letter also explains our expectation that the provider attempt to bill the commercial carrier. After the deadline date (60 days from the date of the letter), TPL will recoup the money electronically. Providers are asked not to submit checks or payments as a result of any payments they receive from the commercial carrier for the claims in this recoupment project, but they should supply documentation as explained in the project instructions to HMS to confirm receipt of denial from the commercial carrier.
    * Since these are MA reclamation claims, the commercial carriers must honor the timely filing limits imposed by the Public Welfare Code under 1413(b)(c)(1)(2) related to MA claims presented for payment within five years of the date of service for claims with dates prior to July 1, 2007, and within three years for claims with a date of service on or after July 1, 2007. DPW recommends using the Timely Filing letter available on the DPW web site when filing these claims to the commercial carriers.
    * The commercial carriers must also honor claims regardless of the type or format of the claim or a failure to present proper documentation at the point of sale (this includes obtaining prior authorization from the commercial carriers.
    * If co-insurance and deductible amounts are due, the providers should submit a new claim for these payments to HMS according to the instructions included in the project. The new claim forms should be submitted only after the recovery has been completed. Providers will need to supply the ICN associated with the voided/retracted claim (ICN begins with Region Code '54') and the original ICN of the claim. Please send new billing forms only as the old forms will not be accepted.
    * It is recommended that providers contact HMS at the toll-free number supplied in the instructions if there are questions regarding this project.
Title: Re: Medicaid billing
Post by: Jdmontee on July 01, 2009, 01:54:00 PM
Thanks for the input! I was pretty sure of what I knew just wanted to be certain I wasn't missing anything in what I had researched.



Joanne
Title: Re: Medicaid billing
Post by: PMRNC on July 01, 2009, 01:58:59 PM
I was trying to be "delicate" One of my clients in PA was pediatric group and I can tell you we had a ton of cases where the patient had either an individual plan and then would ask us for itemized bill and low and behold we would get an inquiry as they tried to collect from Medicaid.
PA and NJ both have a LOT of this. Many of the times you don't even know they have Medicaid (they withold it on purpose)
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 01, 2009, 02:20:20 PM
ROFLMAO!! Our itemized statements show payment by other payors, so none from any office I work will work for medicaid. Unless patient has proof of payment, they won't pay. *Im moving to PA*

Title: Re: Medicaid billing
Post by: Michele on July 02, 2009, 07:18:12 AM
I'm not that familiar with PA Medicaid but I have seen several in NY (my nephew and my office manager's son) where they have a commercial insurance prime thru mom or dad, but they are eligible for Medicaid due to their disability.  It isn't based on income.

Michele
 
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 02, 2009, 08:51:37 AM
It is income based, and you can work and still not make enough money. Imagine working for minimum wage with a family of 5. Your income allows you to get medicaid, but you still have insurance offered through your employer. The insurance doesn't affect your medicaid eligibility, but your income or assets do.
Title: Re: Medicaid billing
Post by: PMRNC on July 02, 2009, 04:10:33 PM
It vary's in all states. I'm originally from NJ.. if you have another health plan and still have Medicaid..there's a problem.
Don't get me going on this topic. LOL
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 02, 2009, 05:44:13 PM
it may vary as far as the criteria is concerned about obtaining medicaid, but what is across the board is that if you have medicaid from any state, it is always billed last. Medicaid will never be the primary payor to any insurance.
Title: Re: Medicaid billing
Post by: PMRNC on July 02, 2009, 06:07:08 PM
Quote
it may vary as far as the criteria is concerned about obtaining medicaid, but what is across the board is that if you have medicaid from any state, it is always billed last. Medicaid will never be the primary payor to any insurance.

Yes I know.. LOL I think you keep missing my sarcasm.. Let's just say I've seen cases where Medicaid was the primary payor. I didn't say it was right.. :o
Title: Re: Medicaid billing
Post by: Michele on July 02, 2009, 10:16:31 PM
The cases I was specifically referring to were not income based.  Both parents work, both make decent $ (especially the husband) and have a family of 4.  The eligibility for their son was solely on his disability.  They were informed by their case worker that they could get medicaid to cover their sons copays.

Michele
Title: Re: Medicaid billing
Post by: Michele on July 02, 2009, 10:23:07 PM
OK now I've done it!  I got deeper into this topic than I wanted to.  I honestly don't understand it, but I know in one case in particular family income is < $70000 annually, so I'm thinking no way it's income based.  But I'm now leaving this topic because I should know better than to do the forum this late at night, especially after the day I had!   ::)

Michele
Title: Re: Medicaid billing
Post by: PMRNC on July 02, 2009, 10:35:40 PM
Quote
The cases I was specifically referring to were not income based.  Both parents work, both make decent $ (especially the husband) and have a family of 4.  The eligibility for their son was solely on his disability.  They were informed by their case worker that they could get medicaid to cover their sons copays

Yes I know that is true of a few states, PA was one of them I believe..but like Charlene Mentioned.. they still are the last payor. 
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 03, 2009, 06:51:28 AM
Quote
it may vary as far as the criteria is concerned about obtaining medicaid, but what is across the board is that if you have medicaid from any state, it is always billed last. Medicaid will never be the primary payor to any insurance.

Yes I know.. LOL I think you keep missing my sarcasm.. Let's just say I've seen cases where Medicaid was the primary payor. I didn't say it was right.. :o

LOL, oops yeah I guess I did!!
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 03, 2009, 06:53:49 AM
The cases I was specifically referring to were not income based.  Both parents work, both make decent $ (especially the husband) and have a family of 4.  The eligibility for their son was solely on his disability.  They were informed by their case worker that they could get medicaid to cover their sons copays.

Michele


Yes you can get it based upon a disability. We have medicaid for the blind, for the mentally handicapped, we also have limited medicaid programs, that only pay for the part-b premiums (income based), medicaid for pregnant women, family planning medicaid etc.
Title: Re: Medicaid billing
Post by: Michele on July 03, 2009, 11:18:59 AM
Well that is one thing we definitely all agree on, Medicaid is ALWAYS the last payor!   ;D

Michele
Title: Re: Medicaid billing
Post by: PMRNC on July 03, 2009, 03:10:51 PM
Actually.. I remember now.. If Champus is involved THEY become last payor.  :D
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 03, 2009, 03:30:29 PM
Actually.. I remember now.. If Champus is involved THEY become last payor.  :D

No, Champus & Tricare is last to everyone except medicaid. This is the only time they (champus/tricare) is primary
Title: Re: Medicaid billing
Post by: Pay_My_Claims on July 03, 2009, 03:39:33 PM
I will attach the link, but here is the overall statement....

if you have other health insurance
(OHI), do you know how those
benefits coordinate with TRICARE?
Understanding some basic guidelines
can help ensure that your claims are
paid correctly and without hassle.
Depending on the type of OHI plan you
have, your OHI may be required to pay
before TRICARE makes a payment.
Special situations arise if you are entitled
to a public program, such as Medicare,
Medicaid or the Indian Health Service.
TRICARE pays second to Medicare,
but is primary to Medicaid and the
Indian Health Service

http://74.125.47.132/search?q=cache:KR1w5ks0ODsJ:https://www.hnfs.net/res/tricare/beneficiary/home/pdf/-1603094169/BeneBullIssue62005final.pdf+tricare,+medicaid+primary&cd=10&hl=en&ct=clnk&gl=us
Title: Re: Medicaid billing
Post by: PMRNC on July 03, 2009, 04:59:35 PM
ahh yes you are right.. I knew there was something with Tricare..they are last unless with Medicaid..

round and round and round we go.. lol