10/28/2021

Billing Patients with Medicaid Managed Care Plans

We are having issues with most medicaid managed care plans in paying the correct copay,coinsurance, and deductibles after their primary insurance... I have appealed and appealed with no resolution.. they either pay 20% or 20 % or nothing at all and keep telling me I can't bill the patient.. We cannot absorb all these write offs..Why can't we bill the patient when they are not paying correctly. Medicaid denys capitation and then when we sent to the capitation plan, they deny - they dont cover x-rays, surgery and a lot of other codes

There is nothing that can be done about this because these patients are receiving medical assistance, they cannot be held financially liable for any balance after Medicare or their primary insurance. All providers must accept the payment from FFS Medicaid or the patient’s Medicaid Managed Care plan as payment in full. Consequences for billing the patient may result in sanctions that will have a much more substantial effect on the finances of the practice from Medicaid, Medicare, or both entities. Medicaid (and Managed Care plans) have always paid lower than Medicare and commercial insurances in New York State. The only legal way to bill a patient for their co-pay, co-insurance or deductibles is to become non-par with all Medicaid plans, and make a patient sign a waiver for every visit that must be kept on file that the practice is non-par with all Medicaid plans and that they are voluntarily being seen by a non-par provider and will be responsible for any patient responsibility per their primary insurance. If these statements are not obtained for every single encounter if non-par with Medicaid, or if you are par and a patient is billed, it is a legal issue that can lead to disciplinary action.