Payments > Patient Billing

OON question

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Anne:
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:
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:
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:
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:
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.
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