Dual Medicare-Medicaid Billing Problems

July 12th, 2018 - Wyn Staheli, Director of Research
Categories:   Medicaid   Medicare   Insurance   Billing  
0 Votes - Sign in to vote or comment.

It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):

A state plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual. - 42 CFR § 447.15 Acceptance of State payment as payment in full

According to this law (above), the only amounts you could collect from the patient for covered services, are the Medicare allowed deductible, coinsurance, and/or copayment. However, according to Medi-Cal’s Provider guidelines, you cannot do that. It states “Providers must not bill the recipient for private insurance cost-sharing amounts such as deductibles, coinsurance or copayments…”  Bottom line: you must carefully review your state law. Balance billing covered charges is always illegal.

Another important thing to check is whether or not the patient is enrolled in the Qualified Medicare Beneficiary (QMB) program. This is critical because if they are, it is illegal to bill them for any cost sharing (i.e., co-pays, deductibles, or co-insurance) on covered charges. You may bill Medicaid for these costs, but coverage is determined at the state level. Even if you are not enrolled as a Medicaid provider, you cannot bill the patient for these amounts. CMS recently released a MLN Matters (SE1128) on this subject because it is such a problem. CLICK HERE to learn more about the QMB program.

So the next question is, what do you do about noncovered charges?

When services are not covered by Medicaid (e.g., they exceed frequency limitations, considered experimental), a healthcare provider is allowed to enter into a written agreement with the patient where the patient agrees to pay out-of-pocket for the services. This written agreement is like the ABN for Medicare noncovered services. It must be completed on a Medicaid-approved form (click here to see Montana’s form), and be signed and dated by both the provider and patient BEFORE services are provided. Utah’s agreement is called “AGREEMENT OF FINANCIAL RESPONSIBILITY- MEDICAID” and Montana’s is called “CUSTOM AGREEMENT FOR MEDICAID NON-COVERED SERVICES.” Just do an internet search on “medicaid non covered services waiver form” and include your state and you should be able to find yours.

Be aware that states can have additional requirements regarding noncovered services. For example, according to the Utah Medicaid Provider Manual, you may bill the patient for noncovered services only when all of the following limited circumstances are met:

    1. The provider has an established policy for billing all patients for services not covered by a third party. (The charge cannot be billed only to Medicaid patients.)

    2. The patient is advised prior to receiving a non-covered service that Medicaid will not pay for the service.

    3. The patient agrees to be personally responsible for the payment.

    4. The agreement is made in writing between the provider and the patient, which details the service and the amount to be paid by the patient.

Regardless of the state in which you reside, healthcare providers are required to let their patients know when a service is not covered by Medicaid BEFORE providing that service. Look up “non-covered services” in your state Medicaid provider manual to make sure you have all your bases covered.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Medicare Updates -- SNF, Neurostimulators, Ambulance Fee Schedule and more (2022-10-20)
October 27th, 2022 - CMS - MLNConnects
Skilled Nursing Facility Provider Preview Reports: Review by November 14 - Help Your Patients Make Informed Health Care Decisions - Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes...
2023 Evaluation & Management Updates Free Webinar
October 24th, 2022 - Aimee Wilcox
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
Are Leading Queries Prohibited by Law or Lore?
October 13th, 2022 - Erica E. Remer
AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag. Halacha is law; it is the prescriptions...
2023 ICD-10-CM Guideline Changes
October 13th, 2022 - Chris Woolstenhulme
View the ICD-10-CM Guideline Changes for 2023 Chapter 19 (Injury, poisoning, and certain other consequences of external causes [S00-T88])The guidelines clarify that coders do not need to see a change in the patient’s condition to assign an underdosing code. According to the updated guidelines, “Documentation that the patient is taking less ...
Z Codes: Understanding Palliative Care and Related Z Codes
October 11th, 2022 - Gloryanne Bryant
Palliative care is often considered to be hospice and comfort care. Palliative care is sometimes used interchangeably with “comfort care” and then again sometimes with “hospice care.”  But these terms do have slightly different meanings and sometimes the meaning varies depending on who is stating it. The National...
2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Yes, You Have What It Takes To Lead Your Practice And Your Profession
September 20th, 2022 - Kem Tolliver
If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association