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Medicaid & Pt Resp ABN

melheffley

Networker
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I have a question about billing a Medicaid patient for certain services. I have contacted a represenative with CMS through the Ohio Dept of Insurance with no response. We are an OB-GYN office with a rather large Medicaid population. We understand that Medicaid does not accept the global OB codes 59400 and 59510. We have run into situations where the patient has primary insurance through a commercial carrier and secondary coverage through Medicaid. The commercial carrier REQUIRES us to bill the global OB CPT. Please see the example of our problem below.

Patient has Anthem insurance primary, Ohio Medicaid secondary. Patient has Anthem coverage for the entirety of her pregnancy (14 antepartum visits, vaginal delivery and post-partum care). We bill CPT 59400 to Anthem. When this claim is processed by Anthem, there is a $500.00 payment and $1300.00 is applied to the patient deductible/coinsurance. Since Medicaid does not recognize the CPT 59400, we are told that we must adjust off the remaining balance. In that instance, our providers have given 10+ months of care for $500.00.

The Medicaid Advantage Plans (Caresource, Molina) allow us to submit all the DOS that the patient was treated for antepartum care to them. They calculate what their payment would have been if the DOS were billed separately, deduct any payment by the primary and remit any balance due.

I attempted to do this with a Ohio Medicaid patient and was contacted by a provider representative (Jeff, I believe). I sent the claims for all DOS where the patient had antepartum care, along with the primary EOB and an adjustment form showing our rationale as to why they should pay. The representative called to tell me that we could NOT do this, it was illegal. We were submitting claims to them for payment when we had already received money from the primary. That we are changing the codes to get more money. I asked him how we are supposed to get paid appropriately for the services that we have given. He stated that if we had an ABN signed by the patient prior to the services, we could bill the patient. We questioned this, but started having all of our pregnancy patients sign an ABN at their first appointment letting them know Medicaid will not cover the balance left by their primary insurance for global OB. The ABN states that by the patient signing, they agree agree to continue with care at our office and become financially responsible.

Does anyone know if this information is accurate? Is there a specific ABN form that needs to be used? Please help!! We are located in Ohio.
 
Messages
4,466
Location
Milwaukee WI
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Healthcare attorney

The best source for legal questions in your state is your practice's healthcare attorney. This issue is too important to your practice to rely on the advice/opinions of fellow coders, many of whom aren't even in your state. You have a legal question and should get qualified legal advice.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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