Medicare/Medicaid when Medicare does not pay

Llynn54

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I work in a Substance Use Disorder Inpatient Treatment facility that has recently changed how and who we bill for State paid residents. If a patient has both Medicare and Medicaid, but Medicare will not pay because they do not cover inpatient chemical dependency treatment and we as a facility do not have a Medicare agreement, will Medicaid pay? The issue has come up because of the way we report these individuals. If we report them as Medicaid, the BHO we are reporting to is entitled to a Federal match. If we report them as Non-Medicaid, the BHO is not entitled to the Federal Match. I have not been able to get a satisfactory answer from the BHO we are reporting to and have had to change my report for the past two months three times. Any help or assistance with this would be greatly appreciated. Thank you!
 
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I work in a Substance Use Disorder Inpatient Treatment facility that has recently changed how and who we bill for State paid residents. If a patient has both Medicare and Medicaid, but Medicare will not pay because they do not cover inpatient chemical dependency treatment and we as a facility do not have a Medicare agreement, will Medicaid pay? The issue has come up because of the way we report these individuals. If we report them as Medicaid, the BHO we are reporting to is entitled to a Federal match. If we report them as Non-Medicaid, the BHO is not entitled to the Federal Match. I have not been able to get a satisfactory answer from the BHO we are reporting to and have had to change my report for the past two months three times. Any help or assistance with this would be greatly appreciated. Thank you!

There's a couple of things going on here. Quick question first, is this a free-standing substance abuse facility?

If a patient has both Medicare and Medicaid, any non-par provider is required to accept assignment by law. This includes providers who have opted-out as well.

As far as Medicaid goes, there's no black and white answer as to whether or not the patient's MD will pay. Each state is different when it comes to dual eligibility, programs like QMB or SLMB. If a patient has QMB, you're required to accept any payments from Medicare and/or Medicaid as payment in full, even if Medicaid doesn't pay anything. There's also QMB or SLMB "Plus", which is the equivalent to full Medicaid, I believe.

That being said, because you're accepting assignment, after the claim is processed by Medicare, it'll then automatically cross-over to the patient's Medicaid. Payment may or may not come out of that, but in the end, because you've accepted assignment, I don't think you have any options other than reporting the patient as Medicaid for your situation.
 
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