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Medicaid as Secondary

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PMRNC:

--- Quote ---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.
--- End quote ---
 

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.

RichardP:
... 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:
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.   

RichardP:
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:

--- 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.
--- End quote ---

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. 

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