02/06/2018

Insurance and Patient Responsibility for 11721-UHC MCR-Primary & Medicaid-Secondary

We have a patient with UHC Medicare Solutions primary and Medicaid secondary. The UHC specialist copay is $45.00. UHC pays $0 on a claim for 11721 as the fee schedule is less than the $45.00 copayment. The claim then gets submitted to Medicaid, who also ends up paying $0 because the copayment is less than Medicaid's fee schedule. Is it true that we cannot bill the patient their UHC copayment and end up rendering services free of charge? Thank you.

It is true that as long as the patient is Medicaid eligible, they cannot be held responsible for any balance, even patient responsibility that is assigned by Medicare or a Medicare advantage plan like United Healthcare.

However, based on the circumstance listed in the inquiry, care should not be rendered for free. If United Healthcare applies the allowed amount for the nail debridement to their specialist copay, it should be billed to Medicaid for processing. Medicaid should be paying a portion of the charge, up to their allowed amount. As per the current fee schedule from New York State, $12 of the $45 copay should be paid by Medicaid for CPT 11721, and the remaining $33 balance would need to be written off as a contractual adjustment.