03/23/2022

Billing Emblem/HIP-Dual Eligibles-Deductibles

When we bill Emblem health/Hip(and many other health insurances) member who has dual eligible plan (Medicare & Medicaid), the insurance company does not pay us for deductibles and states that we have to bill Medicaid. They also state not to bill the patient. However since patient has dual eligible insurance, the insurance company is supposed to be paying in full. On the other hand Medicaid is paying the insurance company and will not pay double for the same service. What other podiatrists are doing regarding this? What we should do in this case ?

When a patient is a dual eligible beneficiary with Medicare and Medicaid, the benefits may not be combined with the same plan. Using EmblemHealth as an example, if the allowed amount for a claim is applied to the patient’s annual deductible, the patient cannot be billed under any circumstances.

Any patient responsibility, whether co-pay, co-insurance, or deductible, must be billed to Medicaid as secondary. When verifying eligibility at the time of service, it is just as important to verify Medicaid eligibility in addition to Medicare eligibility.

Many patients are not enrolled in traditional Medicaid and have their benefits through a Managed Care plan, which a provider would need to submit the claim to for partial reimbursement of the deductible or other patient responsibility from the Medicare Advantage Plan. Claims would need to be billed to the secondary insurance, who would reimburse services up to their allowed amount with the balance being written off as a contractual adjustment. Unless the patient is notified prior to services being provided that the practice is non-par with Medicaid and signs a statement that they will pay for any patient balance, providers cannot hold patients responsible for these balances.