Question Medicaid billing for pts with private primary insurance

saylorme

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Having completed my medical insurance specialist course, it is my understanding that it is illegal to charge a patient for goods and services that they would be able to obtain for free via medicaid, including glasses and eye exams. For this reason it is my understanding that patients with medicaid coverage must choose a medicaid frame, even if they have a private primary insurance. However, my employer has the policy that medicaid patients must pay the copay that is listed on the primary insurance, and must choose a pair of glasses frames from the private insurance's covered frames for their first pair. They may then obtain a second pair of glasses for free using their medicaid coverage. I have been disputing this with the owner since I was hired in July, but whoever helped them set things up when they bought the business in 2015 continues to insist it should be done the way they do it. I am concerned that they have been breaking the law by using this policy.

So this is the question, should a medicaid patient with private primary insurance be allowed to choose a medicaid frame in order to obtain free glasses, and should medicaid's coverage cover the copay for the exam?
 

kenolsen

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Hi,
Medicaid is always the payer of last resort. In this scenario if a patient has both a private/commercial insurance and Medicaid- the commercial benefit is always taken first, therefore any cost sharing for frames under the private/commercial insurance should be billed to Medicaid. The patient can additionally utilize the full benefit under Medicaid for a second pair and would therefore be restricted to the Medicaid only frames. The same logic of COB applies to the eye exam, you would bill the primary insurance first and then bill the remaining balance to Medicaid. Please note that is some states, it is required that providers register with the Medicaid agency as a provider in order to be paid.
 

saylorme

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Since posting here, I had my inquiry routed to the head of Ohio Medicaid, who ended up explaining the correct procedure properly for my boss in an email. Something about my wording above was misleading, as I used the same wording to send her the email, and she ended up answering wrong at first. When i asked for clarification, everything came down the way it needed to.

Now the problem is that no one in any of the offices knows how to bill medicaid as secondary when taking into account COB. They're expecting me to write up a manual or otherwise teach everyone, but I never had an externship during my program because of COVID.

Now my inquiry is, is there some resource I can turn to for them to teach me all these procedures so I can make sure everyone is on the same page?
 
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