Billing Medicaid patients for unpaid covered services?

lexifilly

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Hello,
A private company that offers plans for patients that are found eligible for Masshealth (Medicaid) has been inconsistent with payment of services. We have quite a few patients that have claims that should be covered and the insurance company acknowledges their error in denying their claims, though many claims as far back as July of 2018 remain unpaid. They were incorrectly denied, for lack of prior authorization. Prior authorization is not required for first 20 visits of services we provide. Calls, emails and requested spreadsheets have not resulted in payment of all claims that the company agrees are correct and payable. Provider wants to bill patient. These are covered services. Can the office request payment from the patient?
 

chrissyfegan

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Hi there! Typically as part of the contract with a Medicaid MCO you can't collect from the client when the payor neglects to reimburse correctly. If you reach out to your provider rep, you can typically escalate the complaint or potentially even let them know you need to file a complaint with the state department of insurance. In my experience this is something payors like to avoid at all costs and they may try to accelerate payment for you. Hope this is helpful.
 

trarut

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In the state of Ohio, a provider cannot balance bill an active covered Medicaid patient for Medicaid-covered services. If we are not billing Medicaid for a service, it is non-covered by the Medicaid program or precert was denied, we can issue an advance notification but the patient must sign a waiver acknowledging we will not be billing Medicaid and agreeing to be responsible for the fee before we can bill them. If we don't notify them in advance, we can't bill them.

It's in Section 5160-1-13.1 (Medicaid consumer liability) of the Ohio Administrative Code http://codes.ohio.gov/oac/5160-1-13.1v1.
 

asowder

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I completely agree with chrissy....you can't bill the patient but let them know that you are going to give them x amount of time to resolve the situation or you will file a formal complaint with your state department of insurance. And then make sure that you do. Provide them with those spreadsheets that you have outlining the claims that they are failing to pay you in a timely manner on. Good Luck!
 

lexifilly

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Thank everyone for the information.. Got most, but not all previous claims paid though now many are denying incorrectly with a new denial code x38, previous they used 905a. Both have similar description. Battle continues :)
 
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