05/10/2022

Correct Billing for Dual Eligible Patients-Fidelis Medicare Advantage Dual Plan

Hi. We have a pt. with Fidelis Medicare Advantage (a dual eligible plan). Fidelis has not paid anything, it all went to the annual deductible, and says that we can't bill pt. When my staff calls, some reps say it should be paid, it is going back for review, but this has been since DOS 11/4/21.

If a patient is enrolled in a dual eligible plan, the patient cannot be billed for any patient responsibility such as co-pays, co-insurance or deductibles from the Medicare advantage plan. Patients who are enrolled in dual eligible plans have Medicaid coverage secondary, either traditional Medicaid or a managed care plan. The patients cannot be held responsible for any balances. The allowed amount that was applied to the patient’s deductible by Fidelis Care needs to be billed to the appropriate secondary payer. The information from representatives at the insurance company about the claim being paid is misleading. If the patient did not meet their annual deductible at the time of service, the allowed amount was applied to their deductible correctly and should be billed to the next responsible party for partial reimbursement based on the Medicaid allowable, or whichever managed care plan the patient was enrolled in at the time of service secondary to their Medicare advantage plan with Fidelis Care.