Our office has just started to use a collectiion agency, and I am not sure if it is legal to send Medi-cal patients to an agency that ended up to be covered for pregnancy only services. Often are doctors end up treating hospital patients for gallbladder, and they later find out that they have limited pregnancy coverage. They did accept them under the premise that they were covered by Medi-cal ,and we would never normally send them a bill for any remaining balances, but I am not sure if once they treat a Medi-cal patient if they have technically entered into a legal agreement to accept what they may or not pay, which in this case would be "zero." The doctors go into these cases on an emergency basis ,and they are not advised that they will not be paid.
Thanks,
Dee
Emergency services should be covered if they meet the criteria for medical necessity. If you get a claim denial in a situation like the one you described, call Medi-Cal and advise them that the services were provided on an emergency basis - as long as they were initiated in the ED or an Urgent Care facility, and there were
extenuating circumstances that prevented you from calling and verifying benefits for specific procedures (and advising the patient)
before the procedure was done; then you should have
more than enough grounds to appeal the denial successfully. If it really was an
emergency (
by Medi-Cal's definition), then it would be unreasonable to expect the provider to delay treatment, and risk the lives of the patient and her unborn child, to confirm that he'll get paid for his actions first.
The key is,
Medi-Cal has to agree that the services were medically necessary and that they met the criteria needed to be considered "Emergency" care. Most payers base that criteria on the place of service code, provider type, and of course, the nature of the presenting problem. You need to have made an honest effort to verify coverage for the procedure (to the extent possible, given the circumstances), and have a record of why you were unsuccessful - whether it was due to the patient's condition, misinformation from the insurer, or because you were unable to verify coverage due to the insurer being closed. If you did everything in your power to take care of your end, and your appeal denies anyways, then you should be able to bill the patient for the services. (Hint: The EOB
should indicate an amount applied to patient responsibility -
if you're not sure, ask Medi-Cal)
But...
if you had ample time to verify coverage (as in, a day or more), but no one took care of
doing it (i.e., you just saw Medi-Cal and
assumed that they had regular Medicaid, and not pregnancy-only care), then I probably
wouldn't bill the patient - I'm not saying that you
can't, necessarily, but I personally wouldn't consider that a good business practice, on principle. Providers
usually have a contractual responsibility to verify coverage prior to rendering services, and if that didn't happen because somebody dropped the ball, then it's not entirely the patient's fault that they got non-covered treatment. As long as there's nothing in your contract (or provider manuals) prohibiting it, you can bill patients for medically necessary non-covered services; the catch
here, is that the patient should have been advised of the possibility of being made responsible for payment, so they could have made an
informed decision as to whether or not they still wanted to go through with it. If your office never checked to see if such a possibility existed, then you certainly couldn't have communicated it to the patient; and I'm doubtful that they'll be singing your doctor's praises if they get the impression that they were tricked into getting stuck with a bill they weren't expecting to have to pay. That's just my 2 cents, though - you should
absolutely call Medi-Cal and get the answer to this straight from the horse's mouth.
Your agreement to accept Medi-Cal's payment in full for services rendered only applies to covered services - it's to keep you from balance billing them for your contractual write-off amounts and for services that denied as being inappropriately billed (coded), not to keep you from getting paid for providing care that doesn't fall under their regular benefits.
Hope that helps!
