Author Topic: Medicaid as Secondary  (Read 6215 times)

swolfe

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Medicaid as Secondary
« on: January 10, 2013, 04:33:09 PM »
I work at a Dermatologist office. We are not contracted with Medicaid. We have been told if we are contracted with Cigna (or any other insurance) and the pt has Medicaid as the secondary we can not turn them away. We have been billing CIGNA, then they apply the a certain amount to their deductible. Since we are not contracted with Medicaid we can not bill Medicaid. We have been writing off any amount due. Is this what we should be doing? Can we bill the patient for the copay, deductible and coinsurance from their primary insurance since they do know we are not contracted with Medicaid?

Does anyone know the contact information of someone who can answer this question for me?

RichardP

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Re: Medicaid as Secondary
« Reply #1 on: January 11, 2013, 12:11:36 AM »
Generally, if a doctor is not contracted with Medicaid, s/he cannot bill the patient for anything.

More specifically, even if a doctor is contracted with Medicaid, s/he maybe cannot bill the patient for anything.  The logic is that, if a patient can afford to pay their co-pay and deductible, they most likely would not qualify for Medicaid.  The patient has Medicaid only because they cannot afford the co-pay and deductible.  The Medicaid no-bill rule reflects this reality.

Medicaid is a State administered program, and the rules are bound to vary somewhat from state to state.  Also, Medicaid has a number of different programs within a given state.  Bottom line, you would need to check with the patient's specific Medicaid plan to see what options you have, if any.

Finally, if you are contracted with Cigna, my understanding is that you cannot turn any Cigna patients away, Medicaid or not.  That is the point of being contracted with Cigna: you promise to accept Cigna patients.  The only way around this would be if your doctor was not taking on any new patients at all.  But again, that depends on the specifics of your doctor's contract with Cigna.
« Last Edit: January 11, 2013, 12:19:07 AM by RichardP »

macbook

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Re: Medicaid as Secondary
« Reply #2 on: January 11, 2013, 08:43:04 PM »
Scenario 1: Patient has Cigna as Primary and Medicaid as Secondary

If the provider is not contracted with Medicaid, then the provider can bill the patient.

If the provider is contracted with Medicaid then they cannot bill the patient.

To verify this statement, it is best to call your Medicaid State contractor. 

Hope this helps.

PMRNC

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Re: Medicaid as Secondary
« Reply #3 on: January 12, 2013, 12:19:57 PM »
It always amazes me the amount of patients that come in with a group policy as  primary and Medicaid as secondary.. <sigh>  Interesting enough some states whether you par or not won't let you bill the patient if they have Medicaid, however I have a provider who's patient did NOT disclose his Medicaid secondary until he got the bill after his primary paid. Myself and my client did not back down and we were within our legal rights to bill the patient. Yes you should call your local Medicaid first. 
Linda Walker
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RichardP

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Re: Medicaid as Secondary
« Reply #4 on: January 12, 2013, 02:20:21 PM »
It always amazes me the amount of patients that come in with a group policy as  primary and Medicaid as secondary.. <sigh>

Linda, I'm curious what you mean by that statement, particularly the <sigh>.  Given that Medicaid is means-tested (and assuming the state worker did the appropriate means test before granting Medicaid status to patient), Medicaid would be provided by the state as secondary because the patient demonstrated that paying the co-pay and deductible would be a hardship, or would be impossible.  As wages fall and the cost of health insurance rises, I expect there will be many more folks coming online with Medicaid as secondary.

For doctors who are Medicaid providers, Medicaid will pay the co-pays and deductibles due on the primary insurance.  For doctors who are not Medicaid providers, Medicaid will not pay the co-pays and deductibles due on the primary insurance.  In either case, Medicare can rule that you cannot bill the patient - depending on the state, and the particular Medicaid program the patient is participating in.

To split hairs - you and your client may have been within your legal right to bill the patient, but you may not be within your legal right to force him to pay (e.g., sending him to collections) if he was covered by Medicaid on the date of service .  The distinction being, patient may pay, but Medicaid may have the right to require you to refund the money.  But again, the specifics of what is allowable will depend on what state the patient is enrolled in Medicaid in and the specifics of his particular Medicaid program within that state.

We ask our clients' staff to always ask the patient if they have a secondary.  But they don't always remember to do this.  So we also sometimes end up with situations such as what you described.  When we are informed that the patient has Mediciad as secondary, we simply write off what we billed them for (that is our agreement with our clients) and move on.
« Last Edit: January 12, 2013, 02:26:05 PM by RichardP »

PMRNC

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Re: Medicaid as Secondary
« Reply #5 on: January 12, 2013, 03:08:20 PM »
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We ask our clients' staff to always ask the patient if they have a secondary.  But they don't always remember to do this.  So we also sometimes end up with situations such as what you described.  When we are informed that the patient has Mediciad as secondary, we simply write off what we billed them for (that is our agreement with our clients) and move on.
 

I would understand that if I didn't work from the other side.. but I have been on the other side and one of the biggest pieces of fraud comes RIGHT from this type of example.   Think about it JUST from a common sense point of view. What is Medicaid for?  If a spouse has a group health plan to which the family is insured under.. I'm sorry but in the best interest of your client you need to ask "WHY do they have Medicaid". That does indeed go beyond the scope of a typical medical biller. But for me, it doesn't because again, I've worked on the other side.

I spent many years on the "other" side working with health insurance companies. My last position was in healthcare fraud/abuse.  Some of my thoughts and feelings on this issue are political and opinion based. I've also been able to find cases with some of my providers where there was OBVIOUS and distinct fraud going on.  Unless you dig deeper and go beyond what a medical biller does, I don't expect you to understand. I will give you this ONE fact, you can take it or not take it.   MOST times Medicaid is NOT aware of the primary "group" health plan.  That's all I'm going to say. My walk on the other side has provided me with the expertise to spot this.  I work above and on board with the law, my clients appreciate my expertise on this matter. The NORMAL and average medical biller is NOT going to pick up on this type of consumer abuse/fraud. That's ok. I can.  When I do bill a patient who has Medicaid as secondary, yes indeed I make sure legally we can collect in accordance with all laws.
« Last Edit: January 12, 2013, 03:21:33 PM by PMRNC »
Linda Walker
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RichardP

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Re: Medicaid as Secondary
« Reply #6 on: January 12, 2013, 09:35:03 PM »
... in the best interest of your client you need to ask "WHY do they have Medicaid". ... MOST times Medicaid is NOT aware of the primary "group" health plan.

I assume that is the answer to my question re. why the <sigh>.  And to clarify my remark about discovering a patient has Medicaid after we have already billed them - we have to see the Medicaid card, we don't just take their word for it.

I'm learning something here, so please forgive the questions.  And I'm not trying to make you state something in public that you would rather not.

The majority of our patients with Medi-Cal (California Medicaid) have Medicare as primary, and Medicare automatically forwards the bill to Medi-Cal (not that Medi-Cal actually pays anything on it).  But we get the ocassional non-Medicare primary.  So when we send the secondary bill to Medi-Cal, we include the EOB from the primary insurance.  I'm assuming that that is common practice in all states??  Assuming that it is, assuming that the EOB of the primary is attached when one bills Medicaid as secondary, how is Medicaid not aware of the primary insurance - as you imply/state in your quote I included at the top of this post?  Inquiring minds want to know.




PMRNC

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Re: Medicaid as Secondary
« Reply #7 on: January 13, 2013, 01:57:47 PM »
I wasn't referencing Medi/Medi at all. Medicare/Medicaid.    I was referencing group commercial plans with medicaid secondary  :o We had one where the wife presented her husband's group ID he had family coverage through his employer (BIG company) and then later on when we asked her for her copay upon the next visit she asked did we bill Medicaid? Um.. no.    It happens a lot and sometimes I'm really glad I don't work in the offices because curiosity would kill me and I'd have to ask.. "why again do you have Medicaid?"   When we did par with Medicaid and sent bills we would get letter telling us claims were pending or we would get a call from them requesting the primary carrier information because they didn't know about the primary plan.   
Linda Walker
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RichardP

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Re: Medicaid as Secondary
« Reply #8 on: January 14, 2013, 07:43:31 PM »
Thanks for the response.  But one last question.  When you billed Medicaid as secondary, did you attach a copy of the primary's EOB?  We do that in California, but I don't know that all state Medicaid programs require that.  It seems that attaching the primary EOB to the Medicaid billing would make it more difficult to defraud Medicaid.  But that assumes the person receiving the EOB in the Medicaid office would know how to interpret what they were looking at.

PMRNC

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Re: Medicaid as Secondary
« Reply #9 on: January 15, 2013, 10:16:30 AM »
Quote
Thanks for the response.  But one last question.  When you billed Medicaid as secondary, did you attach a copy of the primary's EOB?  We do that in California, but I don't know that all state Medicaid programs require that.  It seems that attaching the primary EOB to the Medicaid billing would make it more difficult to defraud Medicaid.  But that assumes the person receiving the EOB in the Medicaid office would know how to interpret what they were looking at.

Depending on what state, they use claims "PROCESSORS" VS. "Claims Examiners"   Large NON govt contracted carriers have the funds to train their examiners at various levels. I worked at 3 of the top 5 carriers, we could easily make a transition from underwriting to fraud.  Medicaid in SOME states actually uses call centers and it's NOT likely you will speak with a processor.   Govt sponsored health plans administrate at a much lower rate. I got paid twice as much at the carriers I worked at than they do at most Medicare centers, and Medicaid is worse.   It's not unheard of to talk to Medicaid and teach them a thing or two. 
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com