Wiki Medicaid as Secondary Contractual Obligation Write off

[b3ckalano]

I have a patient with commercial insurance as primary, Medicaid as secondary. I'm not sure that their claims paid out properly.

We charged $185 for a service - the primary payer determined they owed $85, the patient owed $25 copay, and the contractual write-off was $75
We sent in a secondary claim to Medicaid and they covered the $25 copay

Medicaid's allowed amount in this instance is $150, which is $40 more than the primary insurance's allowed amount. Shouldn't Medicaid have actually paid $65 ($25 copay + $40 up to the allowed amount)? Or does Medicaid only pay up to the primary insurer's allowed amount?

Thanks for all your help in advance!

 

[sls314]

I have a patient with commercial insurance as primary, Medicaid as secondary. I'm not sure that their claims paid out properly.

We charged $185 for a service - the primary payer determined they owed $85, the patient owed $25 copay, and the contractual write-off was $75
We sent in a secondary claim to Medicaid and they covered the $25 copay

Medicaid's allowed amount in this instance is $150, which is $40 more than the primary insurance's allowed amount. Shouldn't Medicaid have actually paid $65 ($25 copay + $40 up to the allowed amount)? Or does Medicaid only pay up to the primary insurer's allowed amount?

Thanks for all your help in advance!

Each state sets its own Medicaid reimbursement policies. I am assuming you are referring to Oregon Medicaid, so I looked up the information for you

You are correct - Medicaid should allow up to the Medicaid allowable minus what the primary paid. This is directly from the Oregon Health Authority General Rules Provider Guide, page 5:

https://www.oregon.gov/oha/HSD/OHP/Tools/General%20Rules%20Provider%20Guide.pdf

Billing for clients with other insurance
Bill all prior resources (third-party liability, or TPL) before billing OHA.
Do not collect TPL coinsurance, copayments or deductibles from the client if you are also billing OHA for what TPL will not pay.

For clients with TPL (including Medicare), OHA pays the Medicaid allowable rate or fee, minus the previous amount paid.
 If TPL denies the claim, OHA will pay the Medicaid allowable amount of the claim for the covered services.
 If TPL pays part of the claim, and their allowable is less than OHA’s, then OHA will pay the Medicaid allowable amount, minus the amount TPL paid.
 .If TPL pays part of the claim, and their allowable is equal to or more than OHA’s, then OHA will consider the claim paid in full and you will not receive additional payment from OHA.
 If Medicare pays part of the claim, OHA will pay the difference up to the Medicare or Medicaid allowable, whichever is less


If Medicaid's allowable was higher than the commercial insurance allowable, I would follow up with Medicaid regarding the underpayment. Good luck!

 

[b3ckalano]

Thank you Susan, I was digging through documents and getting nowhere. You're wonderful! THANK YOU!