Wiki Patient With Medicaid in 2 States - Who would you bill?

[andersona1229]

I have occasionally come across patients who, somehow & some way, have active Medicaid in two states. For example, they have active Medicaid in Arizona while being active with Medi-Cal at the same time. I've also seen one state have a COB with another state (ex. Nevada Medicaid shows that they're secondary to UT Medicaid). I usually bill the state Medicaid that the patient has on file as their address; using the example from before, if the patient's address is in CA I would bill Medi-Cal but if it was in AZ I would bill AHCCCS. However, in an instance where the first Medicaid denies, how would you handle it? Would you submit the claims to the other state Medicaid or write them off (depending on the denial)? If you did bill the other state Medicaid, would you submit them as primary or secondary? This is a super rare thing that I have seen only a few times, but I wanted to see everyone's thoughts on how they would handle it.

 

[CBLENNIE]

One of the frequent audit findings from the OIG is that states are not catching members who have Medicaid coverage in more than one state in effect at the same time.

So, I would say you do not want to submit the claim to both states because if they figure out your patient incorrectly has Medicaid in 2 states at the same time, they are going to recoup the money. You could get into a situation where both states try to recoup the money because no one knows where the member really resides, and which state should be the active Medicaid plan.

I would suggest that rather than assuming the address the member gave you is they actual residence, I would contact the patient and ask them what state they are actually a resident of so that you have documentation from the patient advising you of where they actually reside. That way you can prove to the Medicaid agency in that state that you were advised by the patient that their Medicaid plan was the plan that was responsible for their coverage for the date of service if there is ever a question from Medicaid on why you billed them.

 

[sls314]

I have occasionally come across patients who, somehow & some way, have active Medicaid in two states. For example, they have active Medicaid in Arizona while being active with Medi-Cal at the same time. I've also seen one state have a COB with another state (ex. Nevada Medicaid shows that they're secondary to UT Medicaid). I usually bill the state Medicaid that the patient has on file as their address; using the example from before, if the patient's address is in CA I would bill Medi-Cal but if it was in AZ I would bill AHCCCS. However, in an instance where the first Medicaid denies, how would you handle it? Would you submit the claims to the other state Medicaid or write them off (depending on the denial)? If you did bill the other state Medicaid, would you submit them as primary or secondary? This is a super rare thing that I have seen only a few times, but I wanted to see everyone's thoughts on how they would handle it.

It's rare because the patient actually can't (legitimately) have Medicaid from 2 states at the same time. You definitely shouldn't bill both Medicaid plans for the same service - that will create a mess.

I agree with the advice above to determine which state is the patient's actual legal residency. (Not just the address they're using for the time being.)

 

[andersona1229]

One of the frequent audit findings from the OIG is that states are not catching members who have Medicaid coverage in more than one state in effect at the same time.

So, I would say you do not want to submit the claim to both states because if they figure out your patient incorrectly has Medicaid in 2 states at the same time, they are going to recoup the money. You could get into a situation where both states try to recoup the money because no one knows where the member really resides, and which state should be the active Medicaid plan.

I would suggest that rather than assuming the address the member gave you is they actual residence, I would contact the patient and ask them what state they are actually a resident of so that you have documentation from the patient advising you of where they actually reside. That way you can prove to the Medicaid agency in that state that you were advised by the patient that their Medicaid plan was the plan that was responsible for their coverage for the date of service if there is ever a question from Medicaid on why you billed them.

The problem with contacting the patient is that we're an independent laboratory and I have no way to contact the patient except for going back to the referring provider. Unfortunately, going back to the referring provider has to go through two more layers of people before I can get an answer (if I even do). On top of that, we frequently have referring providers that don't provide the patient's address so we have to use the facility's address or whatever the insurance has on file. If I have a c/o facility address, I default to the state the services were rendered in. The unfortunate thing about the one I ran into the other day is that we're OON with one of the MCOs and in-network with the other, the claim went out to the payer we're OON with & denied.

And yes, I know they can't have it in both states which is why I mentioned it was rare.