Wiki When primary denies, but the state requires Medicaid to cover the service - what to do?

[JaneSmith75]

Hello,

We have patients who were receiving counseling services through an LPC. Medicare Part C is primary (WellCare) and Medicaid is secondary. Now, WellCare will pay for services if the counseling is provided by an LCSW or PhD, but recently they've denied for LPC credentials. What do we do, if the patient has Medicaid as a secondary? Is there ever a time when it's appropriate to ask a Medicaid beneficiary (who has Medicaid as a secondary insurance) for prompt payment when knowing the primary insurance will deny the claim for future appointments?

Does anyone know of a CMS link I can refer to?

Thank you kindly,

Diane

 

[amyjph]

https://www.jdsupra.com/legalnews/cms-s-updated-advance-beneficiary-5570493/

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/QMB

https://www.aapc.com/blog/34357-balance-billing-is-it-legal/ (be aware this is a 2016 post)

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1128.pdf

I think this one specifically answers what you are asking:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/medicare_beneficiaries_dual_eligibles_at_a_glance.pdf

"Dually Eligible Beneficiary Billing Requirements ● You must accept assignment for Part B-covered services provided to dually eligible beneficiaries. Assignment means the Medicare Physician Fee Schedule (PFS) amount is payment in full. Special instructions apply when you provide an Advance Beneficiary Notice (ABN) to a dually eligible beneficiary, based on the expectation that Medicare will deny the item or service because it isn’t medically reasonable and necessary or is custodial care. ● You can’t bill the dually eligible beneficiary up front when you provide an ABN. ● Once Medicare and Medicaid adjudicate the claim, you may only charge the beneficiary in these circumstances: ● If the beneficiary has QMB coverage without full Medicaid coverage and Medicare denies the claim, the ABN could allow you to shift financial responsibility to the beneficiary under Medicare policy. ● If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or won’t pay because you don’t participate in Medicaid), the ABN could allow you to shift financial responsibility to the beneficiary"

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProgramBasics.pdf