Author Topic: OON question  (Read 3172 times)

Anne

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OON question
« on: May 23, 2010, 02:47:42 PM »
providers that I bill for are OON for all insurance except Medicaid.  some of the patients have medicaid as a secondary, some do not.  We bill the primary insurance and are reimbursed at the out of network rate.  If they have medicaid secondary, then we file for the medicaid, unless of course the primary insurance pays more than what Medicaid allowable is.  If the patient does NOT have Medicaid secondary, is it alright to give them a discounted bill and is it ok if it's less than what we are reimbursed by medicaid for other patients?  Or is that considered fraud?

medauthor

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Re: OON question
« Reply #1 on: May 23, 2010, 07:46:07 PM »
Wouldn't most primary ins 'allowed amounts' be more than what Medicaid would allow?
Michelle Rimmer, CHI, CPMB
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Anne

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Re: OON question
« Reply #2 on: May 23, 2010, 10:20:46 PM »
no, not for children with special needs.

PMRNC

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Re: OON question
« Reply #3 on: May 24, 2010, 10:49:37 AM »
I'm still blown away at the notion there are a lot with primary insurance and Medicaid secondary? Usually when I run across that where there is a group plan in place and then Medicaid..that usually spells some fraud.. but ok I'll skip over to your question, no you can't discount them routinely, unless you file and claim the discount with the primary.
Linda Walker
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blhoffman

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Re: OON question
« Reply #4 on: May 24, 2010, 11:18:30 AM »
Hi Anne,

I work Pediatric Home Health Care and our patients are very sick children. The majority of our patient's have a Primary and we are OON or our service is non-covered and paid for by a Secondary which is in most cases a medicaid plan.

We have a few patient's that do not qualify for Medicaid and have no Secondary - these patients are billed the full amount once denial is received by Primary. We do have Hardship Rules and Regulations that are followed to consider a reduction of the expected amount or setup a payment plan.

We have a very few patients that are SelfPay with no insurance coverage and they pay full rate. Again if they qualify under the Hardship Rules we have in place then they can be considered for a reduction on the expected amount and a payment plan setup.

Anne

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Re: OON question
« Reply #5 on: May 26, 2010, 08:49:11 AM »
I'm very distressed to think that Linda thinks there is some sort of fraud involved.  We have lots of documentation, get Medicaid authorizations, etc for each patient.  Follow all the rules that we know about.  I've been to Medicaid workshops and seminars, spoken to people at Medicaid and the provider rep. several times.  Sure don't want to be doing anything fraudulant however, so I'm wondering what you mean.  In fact, it would be devastating.

Pay_My_Claims

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Re: OON question
« Reply #6 on: May 26, 2010, 01:07:37 PM »
What she is referring to (i believe)  is for medicaid recipients you should have low income so you shouldn't have medicaid & private insurance. I have been a medicaid recipient before and there are varying situations in which you can have both private insurance and medicaid.

Case #1. I was employed but my employer (even so now) does not cover your family, but allows coverage on the employee. Although I worked, my income was still below the national average (poverty level) so me and my children were able to qualify for medical assistance (medicaid). NC now has NC Healthchoice for  those that don't qualify for medicaid, but are still low income families, so they insure the kids, with a cost share to the parents. ($5.00 copay)

Case # 2. I was terminated (can you believe someone would fire me :-)) from my employment, and filed for benefits. NC medicaid, once approved, your children are eligible for a period of 1 year, where I was on a 3 month temporary medicaid basis. I was only unemployed for 2 weeks (got my old job back), however I was still eligible for the medicaid for the 3 months, while my kids were on it for that year. So being eligible after 90 days for insurance, my kids would therefore have both private and medicaid.


Just because you have private insurance does not mean "fraud" when you have medicaid. You can get medical coverage from McDonalds and still be eligible for medicaid.


Anne

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Re: OON question
« Reply #7 on: May 26, 2010, 03:12:47 PM »
there are special programs in Medicaid for children with special needs, not necessarily based on financial need.  CHCSN and CCP.  And other programs also. 

Pay_My_Claims

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Re: OON question
« Reply #8 on: May 26, 2010, 06:31:31 PM »
OH, I'm aware, I had to get auth's for those special medicaid programs all the time. As a financial rep, i pre-screen clients that has no insurance for medicaid, healthchoice, and hardship apps.

blhoffman

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Re: OON question
« Reply #9 on: May 27, 2010, 11:31:21 AM »
Anne,
Our children are all special needs and fall under the programs of Medicaid. As I said, the patients with Commercial Group Health Insurance plans (through their working parents) do not pay for these services the majority of the time.

They are eligible for coverage through the program Medicaid plans (not due to income), who are very much aware of the Primary insurance. It is the Medicaid website that we check eligibility on our patients for Primary, Secondary and Tertiary.

We also obtain authorizations, submit appeals, and medical records. We supply the denial letters from the Primary or denial EOB's from the Primary when we submit our claims. We are not committing fraud. Besides we just had our audit done at all four offices and we are sqeaky clean. I wouldn't get so upset.
 ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D ;D

Anne

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Re: OON question
« Reply #10 on: May 28, 2010, 11:46:21 PM »
I really didn't think we are doing anything fraudulant - it was just surprising to hear that someone suggested that.  Anyway,  my REAL question in the first place was about charging a patient (one that does NOT have secondary insurance).  Provider is Out of Network for all insurance, except Medicaid. 

example: all patients are charged $140 per hour (which is the medicaid allowable for this type of service) insurance pays $50. for example.   can we charge the patient that does not have secondary insurance the difference up to $120 per hour (which in this case would be $70)? or do we have to charge them what we are paid when the patient does have Medicaid?

Pay_My_Claims

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Re: OON question
« Reply #11 on: May 29, 2010, 08:18:13 AM »
why not treat them as cash clients. we gave cash clients a 10% discount . you charge 140, client pays your fee minus the discount because they are oon. you code it as office discount, and file the claim NON ASSIGNED. this way client gets reimbursed what the insurance pays. the debt is already 100% paid up front.

this way you don't have to worry about fraud

Anne

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Re: OON question
« Reply #12 on: May 31, 2010, 08:09:48 AM »
yes, that sounds like what we should do.  thanks.