Wiki Commercial Primary, Medicaid Secondary

[vero0302]

Hello, I am hoping I can get some clarification on this topic. If a patient has a commercial insurance as primary (ie BCBS) and a Medicaid HMO (Molina) as secondary and the primary paid the vaginal delivery claim at their allowable rate but the patient has co-insurance and deductible to meet however Molina didn't pay any of it because primary paid over their max allowable, can we bill the patient for deductible and co-insurance due from primary?

I found this on AAPC website:

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.


So reading this gives me the impression that we can bill the patient, however other sites say differently. I am in the state of Florida. Any help is greatly appreciated!

Thank you,
Veronica

 

[vanessamoldovan]

The rules regarding whether you can balance bill a Medicaid patient are specific per state. Medicaid is a state program, not a federal program. For example, in the state of Illinois, regardless if the provider is contracted or not, they may not bill the patient if they "accept" their information. However, if a non-contracted provider doesn't make a copy of the card or enter it in the system, then they may bill the patient. Also, in the state of Illinois, if the provider is contracted, then they must always follow the rules and guidelines of the payer and/or state. Some HMOs, like Molina, will have patient responsibility and, per the EOB, the patient is responsible for a copay/coinsurance/deductible. So my advice to you is to research on the website for Florida Medicaid. I'm certain you will find your answer.