Wiki Unpractical payment

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We basically take all insurance plans include Medicare/Medicaid (California Medi-Cal). This patient has this Primary Commercial Plan which has a $90 co-pay and Secondary as Medi-Cal (CA Medic-aid). According to Medicaid rule, we can't take his co-pay so we ended up getting paid $2 for this visit.

Questions:
[1] You guys have any good idea how to overcome this (getting paid a bit more) ?

[2] If we tell the Commercial Insurer that we don't take that specific plan but all other plans inside this Commercial payor, is it a practical solution? Will Medi-Cal pay us?

Thanks in advance.
 
Hi there, this looks like a combination contractual/regulation issue.
1. If Medicaid regulations state you can't bill the commercial plan and you take Medicaid then you must follow their rules for payment. You can't ask the patient for more money.
2. Are you asking about cancelling - or not renewing - your contract for a specific plan with the contractor? If so, yes that is always an option. You just need to follow whatever the contract requires for ending acceptance of that plan (and of course notify all your patients who are on that plan).
 
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Are you not submitting it to their primary commercial plan first for payment? You should be able to get a decent payment from primary, regardless of copay, then Medi-cal should pick up the remaining or possibly need to adjust as max payable already paid by primary. Per Medi-Cal:

"Even if you have other health coverage such as health insurance from your work, you may still qualify for Medi-Cal. If you qualify, Medi-Cal will cover allowable costs not paid by your primary insurance. Under federal law, Medi-Cal beneficiaries’ private health insurance must be billed first before billing Medi-Cal. 10 law, Medi-Cal beneficiaries’ private health insurance must be billed first before billing Medi-Cal."

Source: https://www.dhcs.ca.gov/Documents/myMediCal.pdf
 
Are you not submitting it to their primary commercial plan first for payment? You should be able to get a decent payment from primary, regardless of copay, then Medi-cal should pick up the remaining or possibly need to adjust as max payable already paid by primary. Per Medi-Cal:

"Even if you have other health coverage such as health insurance from your work, you may still qualify for Medi-Cal. If you qualify, Medi-Cal will cover allowable costs not paid by your primary insurance. Under federal law, Medi-Cal beneficiaries’ private health insurance must be billed first before billing Medi-Cal. 10 law, Medi-Cal beneficiaries’ private health insurance must be billed first before billing Medi-Cal."

Source: https://www.dhcs.ca.gov/Documents/myMediCal.pdf
Apologize I wasn't detail enough. For this CPT, we bill $92. His insurance co-pay is $90. Since he has Medi-Cal as secondary, we can't take his co-pay so the insurance pay $2. That's the problem.
 
From my experience, in most states, Medicaid secondary will pay UP TO their allowable less any payment already received.
So you bill $92, which the primary allows the full $92 (PS I would check my billing amount if you have a carrier allowing the full billed amount).
Primary applies $90 to pt copay, pays $2.
Medicaid should receive a claim showing this. Medicaid's allowable for the code is $50, with no patient responsibility. Medicaid should then pay $48 and you adjust off $42. (Medicaid $50 allowable less $2 paid from primary). If Medicaid's allowable is $2 or less, you won't receive any additional payment.
You can't just tell the primary insurance you don't take that specific plan if you are contracted. You can terminate your contract with whatever your termination clause is, but it would be for all patients with that plan.
 
Apologize I wasn't detail enough. For this CPT, we bill $92. His insurance co-pay is $90. Since he has Medi-Cal as secondary, we can't take his co-pay so the insurance pay $2. That's the problem.

What is Medi-Cal's allowed amount for the same service? As Christine mentioned, Medi-Cal should pay up to its allowable charge for the service minus the $2 that the primary paid.

It sounds like you need to clarify with Medi-Cal that the primary insurer only paid $2 and the other $88 is still a copay balance for the patient. It's possible that's not coming over clearly on the electronic claim.

Either way, Medi-Cal is the one you need to pursue to get the additional payment. Up to whatever Medi-Cal's allowed amount for the service is.

Also, 100% agree with Christine - if you're charging $92 and the insurance allowed amount is $92, your charges are too low and probably need to be reviewed. I'm sure you're losing revenue on "lesser of" clauses.
 
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