Wiki Billing out of state Medicaid

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GosiaM

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Our provider saw patient with out of state Medicaid (VA Medicaid) at the hospital last year. Because we are non- par with that plan we were unable to even verify patient's eligibility.
I have few questions.
Are obligated to honor that Medicaid plan?
Can we bill out of state Medicaid?
In the above case, we transferred the balance to patient and have already sent 3 statements but he has never responded. Are we allowed to forward this account to collection?
I was looking for the information but can't find a clear answer. Thanks in advance for any suggestions.
 
Since you are not credentialed with VA Medicaid, I do not believe you are obligated to honor it, although best practices would dictate that you inform the patient of this BEFORE seeing him or her.
 
Yes you can bill out of state Medicaid. If you participate in Medicaid in the state you do business, Federal law prohibits billing Medicaid patients so I would not send to collections. Now if they are on a Medicaid Managed care and the managed care denies say for not being authorized it would be a write-off as well. Obviously after using any appeal rights (if its worth the time and effort to fight the denial). I work for a health plan that does Medicaid managed care and we pay all the time for out of state care as long as its covered service or is authorized if authorization is necessary. We pay using our states Medicaid rate for out of state providers.
 
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CodingKing said:
If you participate in Medicaid in the state you do business, Federal law prohibits billing Medicaid patients so I would not send to collections.
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could you please post what federal law(s) would prohibit this? in the 3 states I've worked, medicaid did not pay for out of state providers, and I don't understand why an Idaho provider as an example would be prohibited from balance billing a Washington medicaid member, since the Idaho provider will not be reimbursed by Washington medicaid.
 
If you send a bill to an out of state Medicaid, they will require you to fill out all the paperwork to become a participating provider before processing your claim. I know we went through this with Medicaid of NY. They kept sending the paperwork back for various reasons, taking months to process it and reject it and return it to us. By the time we finally got it all settled, they denied the claim as past timely filing. We have never, ever billed an out-of-state Medicaid successfully. We bill the patients. All of our charges for these are inpatient so we have no choice but to see the patient and the physicians have no way of knowing the patient has out-of-state Medicaid anyway.

I know of no law or statute which states you must treat a patient for free because they have Medicaid of Nevada and are serviced in Pennsylvania, or Medicaid of Colorado and are serviced in Vermont, etc.
 
There is no law that says participation is Medicaid is a requirement. There is no law that says that just because you participate in Georgia Medicaid, that you must also participate in Alabama Medicaid (for example). If you participate in the state that you are billing, then you can only bill the patient the cost-share amount, if there is one. If you DO NOT participate in a particular state's medicaid program, you cannot bill them for the services, and should bill the patient instead. As I said in my earlier post, best practices would dictate that you inform the patient of your participation status before services are rendered.
 
I've never been actually able to find the law myself. it's just been ingrained in my head over the years by employers. All I can find is 42 C.F.R § 447.15. but it seems fairly limited.

In absence of any laws I'd still say ethically if you know the care will not be covered you should be letting the patient know up front so they can register as self pay or leave.
 
balance billing an out of state Medicaid recipient

we have a patient that resides in Georgia and has Peach street Ga Medicaid, the patient was seen in our ER (FL), because we are out of network with Ga Medicaid the claim continues to deny, should or should be not balance bill out of state Medicaid recipient ? any assistance would be greatly appreciated
 
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