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.

 

[Snuffy72]

In regards to the second patient... did you know prior to seeing patient that that the clinician was not in their plan and was the patient notified prior to the appointment? Did the sign anything agreeing to pay anything leftover from primary? If patient was notified and agreed to still be seen then you can charge them.
If not, they you cannot charge the patient.

 

[Anjeza]

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?

Hi, when BCBS is primary, and Medicare is secondary, and BCBS pays more than Medicare’s allowed amount causing Medicare to deny, you can bill the patient only for the BCBS copay (like the $15)—nothing more. However, when Medicare is primary, and Medicaid is secondary, even if you are out-of-network with Medicaid and Medicaid pays $0, you cannot bill the patient at all, because patients with Medicaid (especially QMB) are protected, and you must accept Medicare/Medicaid as full payment.