Wiki Medicare

[rgilbreath@coniferwellness.com]

I have a tricky situation - BCBS is primary, Medicare is secondary. Medicare denies claims due to BCBS paying out more than the contracted rate with Medicare. BCBS has a copay of $15 that Medicare is refusing to pay. Can I / Do I bill this to the patient?
Second question - Medicare is primary, Medicaid is secondary. This clinician is not in network with this Medicaid plan. I cannot bill patient the difference.... Correct?

 

[kdlberg]

The first one, yes. Medicare is only responsible for covered charges left after the primary payment. The co-pay isn't part of the charge for the service, it's the patient's contract with the primary payer.

For the second one: I'm not sure if this is a Florida rule or a general Medicaid rule but it says "Providers may seek reimbursement from a recipient under the following circumstances [...] The treating provider is not in the plan’s provider network (with the exception of emergency services.)" However, it also says "Providers who submit a claim to Florida Medicaid for reimbursement of a covered service whether the claim has been approved, partially approved, or denied, may not seek reimbursement from the recipient." What it sounds like is that once the claim goes to Medicaid, whatever you get is what you get--whether that's $0 or $1,000.

I would look specifically for the rules in whatever state you're in.

 

[rgilbreath@coniferwellness.com]

Thank you so much for your response. I will dive a little deeper into the second question and find the local ruling. Thank you again.