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Thread: Medicare Participating/Medicaid Non-Participating Provider

  1. #1

    Question Medicare Participating/Medicaid Non-Participating Provider

    AAPC: Back to School
    Our physician is a participating provider with medicare but non participating with medicaid. We were recently informed that we cannot balance bill the patient for coinsurance because he is a participating provider with medicare. We do inform the patient up front that the provider is non participating in medicaid. In addition, Evercare told us it was against the law to collect co insurance or copays from the patient if they have medicaid as secondary and we are non participating.

    Does any one know if this is true and if so where I can find the policy/documentation to support this to show to the provider?


  2. #2


    I would recommend looking in your state's Medicaid Handbook, for starters. A lot of the Medicaid rules are state specific. You can also contact the Medicaid Provider Rep. If you aren't allowed to collect they will know exactly where that rule is.

  3. #3


    I would reccomend checking too, but what they are saying may be correct in your state. I am in Pennsylvania and we can not balance bill Medicaid patients regardless of whether we are participating or not. This holds true for New York Medicaid and Ohio Medicaid as well. One dr in our city (no affiliation with my practice) was recently audited and had to pay thousands of dollars in refunds and fines based on a patient complaint call because the dr. was balance billing patients.

  4. #4
    Join Date
    Apr 2007
    Las Vegas


    We begin encountering so many reasons that we would not be paid by Medicaid for services we provided in good faith to their insureds that we opted to notify our state medicaid that we were terminating our contract per the terms of the contract and notified our patients that as of January 1 of this year that we would not see Medicaid patients. If you are providing services in good faith and under the terms of your contract and getting denied, maybe you should review your contract and decide if it is really worth it financially speaking to give your services away for free and not get paid for what you provide. Our Medicaid provider pays less that what Medicare allows for routine office visits are therefore we were required to write-off the 20% that was the patient portion. I don't about you but if you have a large population of Medicare/Medicaid patients losing 20% of what you are entitled to just because the Medicaid provider allows less that what Medicare pays doesn't seem very fair. In our case, it was costing us almost $ 15.00 per patient and we had a lot of them. In some instances it did mean that our Medicare patients had to seek out a physician who would accept Medicare and Medicaid.

  5. #5
    Join Date
    Apr 2007
    Kachina Coders


    I'm in Arizona but I've found in most cases with Medicaid (AHCCCS here) you cannot balance bill the patient regardless of if the provider is Par or NonPar. Whether secondary or primary. In Arizona I know that even if AHCCCS is not provided to the provider at TOS and is later to be found the patient has AHCCCS (even outside timely) we still may not bill the patient if we are NonPar with their plan unless we can prove their intent, which is rarely possible. We are required to adjust off the balance.

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