Author Topic: Facility Medicaid Billing  (Read 958 times)

mariorodriguez36

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Facility Medicaid Billing
« on: January 18, 2018, 10:23:05 AM »
Has anyone had tons of issues with billing a Texas Medicaid HMO? We submit everything correct then bill denies. Appeals are submitted using plan portal and information isn't received. Has anyone had to submit a complaint to the state? Where did you do so? We are tired and don't know what else to do

Michele

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Re: Facility Medicaid Billing
« Reply #1 on: January 18, 2018, 11:54:54 AM »
Sorry but we haven't had these issues.  We do bill Texas Medicaid HMOs.
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mariorodriguez36

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Re: Facility Medicaid Billing
« Reply #2 on: January 19, 2018, 01:08:10 PM »
How do you handle two ER visits within 24 hours? We have a payer that will pay one claim and the other they global our charges. The TMHP manual states "If a client visits the
Emergency Room more than once in one day, the times must be given for each visit.". We've informed the payer that we do this and they still global our claims.

We were wondering if any other facilities have this issue?

Michele

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Re: Facility Medicaid Billing
« Reply #3 on: January 22, 2018, 10:10:21 AM »
Have you filed an appeal?
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mariorodriguez36

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Re: Facility Medicaid Billing
« Reply #4 on: January 22, 2018, 03:02:24 PM »
Yes, we appeal with all the documentation TMHP states we need but still globals.

Michele

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Re: Facility Medicaid Billing
« Reply #5 on: January 23, 2018, 11:58:36 AM »
Is there a provider rep that can help you?  It sounds like there is an issue on their end.
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PMRNC

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Re: Facility Medicaid Billing
« Reply #6 on: January 23, 2018, 12:58:30 PM »
Quote
How do you handle two ER visits within 24 hours? We have a payer that will pay one claim and the other they global our charges. The TMHP manual states "If a client visits the
Emergency Room more than once in one day, the times must be given for each visit.". We've informed the payer that we do this and they still global our claims.

In one of your posts you mentioned it was a TX Medicaid HMO.. if that's the case I don't think the TMHP would be particularly useful since the HMO plan (PATIENT CHOOSES) will have their own policies and plan provisions.
Linda Walker
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mariorodriguez36

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Re: Facility Medicaid Billing
« Reply #7 on: January 23, 2018, 01:51:58 PM »
Most of our HMOs follow TMHP guidelines. The specific plan we are having issues with is kind of tricky. Some instances they say to refer to the TMHP provider manual but for anything else they inform us they have their own guidelines. We are kind of skeptical of referring to this specific plans provider manual as most of the information is incorrect. For instance last week we found out that our CRNA 1500 claims were needing to be billed with an authorization. We were unaware of this, we called this specific plan and 3 different reps informed us no auth was required. We looked at the manual (which was updated in 2016) and it states auth is required. We called today 01/23/2018 and a rep from this plan informed us that all reps received a memo stating CRNA claims do require auth but to inform providers that no auth is required due to them also barley finding this info out.


Michele

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Re: Facility Medicaid Billing
« Reply #8 on: January 24, 2018, 06:44:02 AM »
This doesn't seem right.  Have you contacted the state?  Even though it's a Medicaid HMO it is funded by the state and they might want to know about the issues you are having. 
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mariorodriguez36

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Re: Facility Medicaid Billing
« Reply #9 on: January 24, 2018, 09:31:06 AM »
We haven't contacted the state at this point. We were working with our provider rep from this plan to try and sort everything out but we have been working with her for almost a year already and nothing has changed. We haven't had to contact the state on a compliant like this before so are unaware of where to call.

PMRNC

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Re: Facility Medicaid Billing
« Reply #10 on: January 25, 2018, 06:39:41 AM »
For a State Plan Medicaid HMO you would contact your state dept of insurance.

Quote
Most of our HMOs follow TMHP guidelines. The specific plan we are having issues with is kind of tricky. Some instances they say to refer to the TMHP provider manual but for anything else they inform us they have their own guidelines.

That's correct, they MAY follow TMHP guidelines, but they don't have to and they will have their own policies as they could. What I would do is when a patient comes in with a Medicaid HMO that you are participating with is first pull the contract. If you are NON par, that's a different story because of course if you are non par with the HMO you won't get paid at all regardless if you are participating with your state's Medicaid plan.

Quote
Even though it's a Medicaid HMO it is funded by the state

Not funded, but overseen by the state dept. The HMO still does not have to follow Medicaid but they do have to follow their own policy plan and carrier provisions.


When you contact the state dept, make sure that you have all documentation ready. For them to help you you must have documented each phone call, who you spoke with, what you were told, MOST state dept's now have online filing guidelines as well. Here's what I found for Texas: http://www.tdi.texas.gov/hprovider/providercompl.html
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crystallibby

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Re: Facility Medicaid Billing
« Reply #11 on: February 26, 2018, 07:02:00 AM »
The problem you are facing is not unique. Sometimes, the medical billing service that you rely upon. Did you check with the company what do they say about this situation? Also, try searching other forums to see if other customers are facing the same situation. If that is true, then you need to consider changing your medical billing service company.

mariorodriguez36

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Re: Facility Medicaid Billing
« Reply #12 on: March 08, 2018, 02:38:46 PM »
@crystallibby- I do the Medicaid billing for our facility. We do not use a medical billing service. We have found the source of our issues with this HMO Medicaid plan. Hopefully we see a resolution soon and are able to start the clean up (even though it wasn't our mistakes)

aoptraininginstitute

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Re: Facility Medicaid Billing
« Reply #13 on: March 21, 2018, 06:32:10 AM »
Sorry but we haven't had these issues.

BikhamHCare

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Re: Facility Medicaid Billing
« Reply #14 on: March 22, 2018, 11:34:07 AM »
Please concern to medical coding agencies.It will suggest all types of solutions.. thanks