Payments > Patient Billing

OON question

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Anne:
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:
Wouldn't most primary ins 'allowed amounts' be more than what Medicaid would allow?

Anne:
no, not for children with special needs.

PMRNC:
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.

blhoffman:
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.

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