Medicaid Billing Guidelines
- By admin aapc
- In AAPC News
- March 29, 2010
- 11 Comments
by Trina Cuppett, CPC, CPC-H
Billing for Medicaid can be tricky, as both federal and state guidelines apply. The Centers for Medicare and Medicaid (CMS) administers Medicaid under the direction of the Department of Health and Human Services (HHS).
The federal guidelines always take precedence over the state guidelines, as the federal guidelines sets the minimum requirements that each state must follow. The individual states may then expand their programs as long as they do not contradict federal guidelines. Expanding a program means that an individual state may opt to add additional coverage, such as: prescription drugs, dental services and prescription eyeglasses, that is not required by the federal guidelines.
While providers and facilities may choose whether to participate in the Medicaid program, those who do must comply with all applicable guidelines, including “balance billing.” It’s also important for providers to understand that Medicaid is considered to be the payer of last resource, meaning that if the patient has other coverages, they should be billed prior to billing Medicaid.
It goes against the Medicaid guidelines to balance bill a Medicaid patient, their family or their power of attorney for any unpaid balance once Medicaid has paid what they allow under the Medicaid fee schedule. This simply means that the provider must adjust off the leftover balance once any applicable charges for a copayment, deductible or coinsurance is met.
NOTE: A balance does not constitute, “coinsurance” due.
42 C.F.R. § 447.15 Acceptance of State payment as payment in full
A state plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual.
Basically, this means that a provider is not to bill the difference between the amount paid by the state Medicaid plan and the provider’s customary charge to the patient, the patient’s family or a power of attorney for the patient.
Billing and coding personnel should be familiar with their state guidelines pertaining the proper procedures and requirements for billing Medicaid.
Example: In North Carolina the Basic Medicaid Billing Guide (April, 2010) contains a wealth of information that is not limited to billing information as it also contains items such as: The List of Standards for Office Wait Times.
It is imperative that billing and coding personnel, providers and administrative staff are knowledgeable of pertinent guidelines to ensure billing and plan participation compliance to avoid exclusion from participating in the state Medicaid plans as well as possible civil or criminal sanctions for noncompliance issues such as improper billing procedures involving balance billing.
Billing personnel can refer to the CMS website: http://www.cms.hhs.gov/home/medicaid.asp for additional information.
North Carolina’s link is attached which will take you directly to the Basic Medicaid Billing Guide (April, 2010) which is a great example of the type of information that is available and it is a free resource.
http://www.dhhs.state.nc.us/dma/basicmed/Section4.pdf
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i would like to verify the state law for georgia pertaining to medicaid billing in reference to patient
if the doctor is not a Medicaid provider can we bill the patient in Florida
I have a question about Medicaid patient’s. Say that you have a patient that has a bill that was turned over to collections and has been in collections for years and now that patient is now saying that the had Medicaid for the date of service in question. Is the bill that patient’s or does the provider’s office have to write it off, even though the patient never said they had Medicaid and never call the provider to tell them.
My question is the same as Marlene. . Say that you have a patient that has a bill that was turned over to collections and has been in collections for years and now that patient is now saying that the had Medicaid for the date of service in question. Is the bill that patient’s or does the provider’s office have to write it off, even though the patient never said they had Medicaid and never call the provider to tell them.
Can a non par provider balance bill a medicaid patient if we have received payment?
My question is can a patient that has old balance that was turned over when they had Medcost insurance for non payment and now is trying to come in the office with Medicaid can we collect on that old balance that is owe and if not going to pay do we have to see the patient again?
how do we bill humana medicaid for crna”s in florida?
My question is the same as Marlene and Carla:
Say that you have a patient that has a bill that was turned over to collections and has been in collections for (5) years and now that patient is now saying that the had Medicaid for the date of service in question. Is the bill that patient’s or does the provider’s office have to write it off, even though the patient never said they had Medicaid and never call the provider to tell them. Can the patient remain in collections since they never provided the Medicaid information? We sent statements and so did the collection agency.
My office manager states that we cannot bill for a visit and procedure on the same claim. Example patient comes in for sutures due to a laceration . Office manager states that we either have to bill for the visit or bill for the sutures. NOT CORRECT!!!! Right????? You bill for the visit at the level of service provided but you also bill for the supplies as well or is that incorporated into the actual procedure code?
Can a provider that accepts an out of state/out of network patient as a Medicaid patient later decide they’re not going to accept the out of state Medicaid and bill the patient as a private pay patient?
Would a provider need to disclose costs and obtain a payment plan agreement before providing services in order to bill as private pay?
This provider obtained prior authorization from a Medicaid MCO, filed the claim incorrectly and was directed to provider services to make corrections. He refused to go through provider services and decided to bill the Medicaid beneficiary as a private pay patient instead. The provider has since sent the account to collections.