How do doctors get paid on dsnp plans?

[keith365]

I had a doctor charge my client $60 for an office visit for a dsnp client. According to the insurance company, this doctor is in network. I called the doctors office, and was told that they don't accept any dsnp plans. But then they asked me an interesting question. If they were to accept it, how do they get paid? My clients co-payment would be $0. Does the state (Medicaid) reimburse the doctor in full? The doctors office would have to bill Medicaid? Or does Medicaid and the insurance company share in the bill?

 

[KandKsmommy]

I had a doctor charge my client $60 for an office visit for a dsnp client. According to the insurance company, this doctor is in network. I called the doctors office, and was told that they don't accept any dsnp plans. But then they asked me an interesting question. If they were to accept it, how do they get paid? My clients co-payment would be $0. Does the state (Medicaid) reimburse the doctor in full? The doctors office would have to bill Medicaid? Or does Medicaid and the insurance company share in the bill?

If it shows as in-network I would have the company do a 3 way call with your client because there is no reason for them to charge him and it is illegal for them to charge a Dual with QMB or above a copay. https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2018-06-06-QMB-Call-FAQs.pdf

As far as how they get paid they receive an initial payment from the DSNP and then any remaining portion gets paid by Medicaid. Anything Medicaid doesn't pay they have to write off.

 

[DonP]

I had a doctor charge my client $60 for an office visit for a dsnp client. According to the insurance company, this doctor is in network. I called the doctors office, and was told that they don't accept any dsnp plans. But then they asked me an interesting question. If they were to accept it, how do they get paid? My clients co-payment would be $0. Does the state (Medicaid) reimburse the doctor in full? The doctors office would have to bill Medicaid? Or does Medicaid and the insurance company share in the bill?

Insurance company is primary and Medicaid secondary. The drs office must bill the ins company and Medicaid. What the ins company doesn’t pay Medicaid pays . I’ve never had an issue . I did have one dsnp person I moved to regular plan as dr wouldn’t accept a dsnp plan and he needed that dr short term . Then I moved back to a dsnp . Hell I had a guy I moved last end of month and I sent him his member info . The drs office refused to accept anything but his ins card . They would not call to confirm coverage . It was nightmare as he had drs appt 1st of month .

 

[StephanieCJ]

Doctor's office bills insurance and then Medicaid. Client must show both insurance card and Medicaid card for the vast majority of plans and doctor must also take Medicaid in almost all cases. We had a client at my office who was going to doctors and only showing plan card and not Medicaid card. He would bring us the bills and we would call and get his Medicaid info to the doctors offices. After the first couple of months, he got the message and we had it all straightened out.

 

[KandKsmommy]

Doctor's office bills insurance and then Medicaid. Client must show both insurance card and Medicaid card for the vast majority of plans and doctor must also take Medicaid in almost all cases. We had a client at my office who was going to doctors and only showing plan card and not Medicaid card. He would bring us the bills and we would call and get his Medicaid info to the doctors offices. After the first couple of months, he got the message and we had it all straightened out.

Yes ideally they should show both cards but some states like Maine don't issue actual cards anymore for QMB instead they have to drag around their letters. If their Medicaid is on file with Medicare it should autocross. Most hospitals and doctors' offices have access to their statement Medicaid system for instance MIHMS here in Maine where they are supposed to double-check everyone's accounts before sending them to collections.

I worked in hospital billing and can honestly most skip this step but if the patient does have Medicaid or QMB they just have to notify the collection agency and the bill gets written off. They put the onus on the hospital/Dr to check if the patient has insurance and even when the people waited until it was too late for us to submit bill to give us their card information and we had to eat it because of the contracts with the insurance companies.

Doctors and hospitals tend not to like any MAPD or DSNP because they are a lot more work to deal with and they can't get away with ordering unnecessary tests due to prior auth requirements.

There is a reason Medicare loses approximately 60 Billion to insurance fraud and it's not just those DME companies sending people back braces. Unbundling, over-ordering testing, and performing unnecessary procedures are real problems in this country.

 

[DonP]

Yes ideally they should show both cards but some states like Maine don't issue actual cards anymore for QMB instead they have to drag around their letters. If their Medicaid is on file with Medicare it should autocross. Most hospitals and doctors' offices have access to their statement Medicaid system for instance MIHMS here in Maine where they are supposed to double-check everyone's accounts before sending them to collections.

I worked in hospital billing and can honestly most skip this step but if the patient does have Medicaid or QMB they just have to notify the collection agency and the bill gets written off. They put the onus on the hospital/Dr to check if the patient has insurance and even when the people waited until it was too late for us to submit bill to give us their card information and we had to eat it because of the contracts with the insurance companies.

Doctors and hospitals tend not to like any MAPD or DSNP because they are a lot more work to deal with and they can't get away with ordering unnecessary tests due to prior auth requirements.

There is a reason Medicare loses approximately 60 Billion to insurance fraud and it's not just those DME companies sending people back braces. Unbundling, over-ordering testing, and performing unnecessary procedures are real problems in this country.

But on the other side mapd CO’s are cheating the govt out of $10 bil a yr by making people appear sicker than they are . The sicker you appear the more the company gets from the govt . CO’s and Fmo’s bend over backwards to support big dsnp producers . In 20 months I built a 6 fig renewal business for ZERO cost

 

[Travis Price]

But on the other side mapd CO’s are cheating the govt out of $10 bil a yr by making people appear sicker than they are . The sicker you appear the more the company gets from the govt . CO’s and Fmo’s bend over backwards to support big dsnp producers . In 20 months I built a 6 fig renewal business for ZERO cost

What does any of this have to do with the question at hand? No one cares about your production.

 

[vic120]

What does any of this have to do with the question at hand? No one cares about your production.

Didnt you know he is a doctor

or at least he plays one on TV




and he gets paid

 

[KandKsmommy]

But on the other side mapd CO’s are cheating the govt out of $10 bil a yr by making people appear sicker than they are . The sicker you appear the more the company gets from the govt . CO’s and Fmo’s bend over backwards to support big dsnp producers . In 20 months I built a 6 fig renewal business for ZERO cost

I don't doubt that. I do a little bit of DSNP but I primarily focus on Med Supp/PDP. I like the benefits of DSNP plans but everyone is always out to switch them on you so I find it a lot more work. My DSNP people are very loyal and I have them trained to say no thank you I have an agent and call me. We also have a lot of carriers making promises but not delivering on them with things like the rides, dental coverage, OTC, and hearing. It's rather maddening.

 

[somarco]

No one cares about your production.