12/27/2016

Billing Medicaid After Medicare

I need clarification about billing Medicaid after Medicare or dual plan visits

Any patient responsibility, whether it’s co-insurance or deductible from Medicare,  co-pay, co-insurance, or deductible from a Medicare Advantage Plan, must be billed to Medicaid as a secondary. Medicaid will make a payment on the outstanding patient responsibility from the primary insurance plan as long as the following criteria are met:

• The CPT code covered by Medicare or the Medicare advantage plan is on the Medicaid fee schedule
• The amount paid by the primary insurance does not equal or exceed the Medicaid allowed amount
• The billing provider is participating with Medicaid
• The patient has active coverage with Medicaid on the DOS

If the procedure code allowed by the primary Medicare plan is not on the fee schedule, the balance is not covered and the balance will have to be written off. If the amount paid by Medicare or a Medicare advantage plan is equal to or greater than the allowed amount by Medicaid, the balance is a contractual write off. If the provider is non-par with Medicaid and the patient has active coverage on the DOS, they cannot be held liable for the balance due to CMS guidelines for dual eligible beneficiaries.

A patient may only be balance billed if they are not covered by Medicaid on the DOS or have benefits that specifically exclude coverage of patient responsibility from Medicare, which should be checked every time a patient comes to the practice.