09/14/2018

Billing for Patients with Primary Commercial Insurances and Secondary Medicaid Plans

We have several patients who have commercial insurances and Medicaid. The primary insurance processes the payment to us as a copay to the patient. We bill Medicaid for the copay and Medicaid denies, therefore, we receive no payment at all for the visit. We have some questions: 1. Is this standard procedure? (not getting paid!) 2. Are we doing something incorrect with our processing which prevents us from getting paid? 3. Are we able to refuse Medicaid as a secondary in this case and have the patient pay the copay? 4. If we refuse Medicaid in the above scenario, would we be able to accept Medicaid Advantage plans, such Blue Choice Option, Fidelis, UHC Community plans? Thank you for your time and I look forward to your responses

• When Medicaid processes claims as secondary, it will only cover services that are both on the Medicaid fee schedule for podiatry, up to their allowed amount for the procedure. If no payment is made by Medicaid and the procedure code is on the Medicaid fee schedule, the amount paid by the commercial insurance is greater than the Medicaid allowed amount and no additional payment will be made. If the procedure code is not on the Medicaid fee schedule for podiatry, even if it is covered by the primary insurance, no payment will be made.
• The ideal way to bill secondary claims to ensure payments are being made for the patient responsibility from the primary insurance is to enter the claim information in ePaces. This would be the easiest and most accurate way to ensure secondary claims are processed by Medicaid with the correct COB information from the commercial insurance. 
• If a patient is active with Medicaid on the date of the visit, they cannot be billed for any co-pays, deductibles or co-insurance if the provider participates with Medicaid.
• Effective January 2018, in order to be a participating provider with all Medicaid Managed Care plans, a provider must be enrolled as a Medicaid provider.