Wiki Medicaid denial question

[michelleaapc2012]

Any advice would be appreciated.
I have an example of a patient that has Humana Medicare Replacement as primary and Medicaid as secondary. Billed amount $2,150. Humana allowed $763.96 and paid $611.17. The coinsurance is $152.79.
Medicaid was billed for the $152.79, but denied. The Medicaid rep. states Medicaid does not pay unless the primary pays 80%. The Medicaid eob says patient responsibility is $0.
Is it correct for Medicaid to deny since Humana didn't pay 80%?
Can the patient be billed in this example or does the provider write off the $152.79?

 

[SharonCollachi]

First, Humana DID pay 80%. It's 80% of the allowed amount, not 80% of billed charges. $763.96 x 80% = $611.17.

But here's the thing... unless it is in the deductible period at the beginning of the year, most of the time Medicaid is going to pay zero and you cannot bill the patient. Here's why:

Most of the time, Medicaid allows half of what Medicare allows. As long as you get more than what Medicaid allowed, Medicaid pays nothing. In your case:

Medicare allowed: $763.96.

Medicaid allowed: $381.98 (half of $763.96).

Medicare paid: $611.17 <-- more than $381.98.

This is why alot of practices won't take Medi-Medi. You never get the copay. In the beginning of the year, when the patient has a Medicare deductible, you'll get Medicaid rates until the deductible is met. So if this procedure was done in the beginning of January, Medicare (Humana) would have paid zero, and Medicaid would have paid $381.98, and that's all you would have gotten.

The patient pays zero.

 

[dkissel]

Our Michigan Medicaid vouchers read paid but at zero dollars to as not cause a "denial" confusion per Sharon's explanation.

 

[Orthocoderpgu]

Reality check. If Medicaid is the secondary payer, don't expect any payment. Don't go chasing Medicaid payments. You can spend more money trying to get the payment than the payment itself.

Excellent explanation Sharon!