In Network, Out of Network, Will Accept

[agentjhc]

He could be talking about UHC dual PPO. But I'm also drunk so I have no clue

The plan I am referring to is Dual HMO. My concern is my client getting billed if UHC doesn't pay. I left a list of PCPs with both ladies just in case.

 

[wehotex]

That may very well be how it works in California, but I know for a fact that's exactly how it works in NY. California has done more with MA/Medicaid coordination of benefits than many other states, but it's usually as simple as a Medicaid provider has to take Medicaid and be done with it. If the person has an MA plan that pays out, all the better for the provider, but part of contracting as a Medicaid provider (or with most other insurance for that matter) means that they can't balance bill the patient.

Scenario 1:

Medicaid + MA with participating provider: MA pays out, Medicaid pays next.

Scenario 2:

Medicaid + PA with non-participating provider: MA doesn't pay out, Medicaid pays, end of story.


You can also contact Medicaid billing to see how they handle it, that's how I got the final answer about this. Medicaid in NY said that if the MA plan pays, they pay after. If the MA plan denies the claim, then they pay, but they need to see either an MA claim paid or denied before they pay. They also do not allow their providers to balance bill their patients.

We've been told that Medi-Cal pays only about 14 cents on the dollar or thereabout. Why would a provider even bother seeing this patient at all? He'd obviously lose $$ on the deal.

 

[Josh]

We've been told that Medi-Cal pays only about 14 cents on the dollar or thereabout. Why would a provider even bother seeing this patient at all? He'd obviously lose $$ on the deal.

I don't know what state we're even talking about with the OP.

Providers take Medicaid alone all the time. The question wasn't about the philosophy of provider billing and profitability, it was about what happens to the member. Again, in California there is an interesting relationship with Medicare and Medicaid and I can't speak to that. What I can speak to is in NY and the way it does work in most states.

 

[agentjhc]

Tennessee. Most are moving from UHC Community Plan to UHC Dual Complete.

 

[Josh]

I'd call up the state's Medicaid office and ask them how the claim would be processed. If it's denied by an MA plan, will they pay the full load? The Medicaid office would be the one's processing the claim so they should know.

 

[yogooglethis]

That may very well be how it works in California, but I know for a fact that's exactly how it works in NY. California has done more with MA/Medicaid coordination of benefits than many other states, but it's usually as simple as a Medicaid provider has to take Medicaid and be done with it. If the person has an MA plan that pays out, all the better for the provider, but part of contracting as a Medicaid provider (or with most other insurance for that matter) means that they can't balance bill the patient.

Scenario 1:

Medicaid + MA with participating provider: MA pays out, Medicaid pays next.

Scenario 2:

Medicaid + PA with non-participating provider: MA doesn't pay out, Medicaid pays, end of story.


You can also contact Medicaid billing to see how they handle it, that's how I got the final answer about this. Medicaid in NY said that if the MA plan pays, they pay after. If the MA plan denies the claim, then they pay, but they need to see either an MA claim paid or denied before they pay. They also do not allow their providers to balance bill their patients.

" I'd call up the state's Medicaid office and ask them how the claim would be processed. If it's denied by an MA plan, will they pay the full load? The Medicaid office would be the one's processing the claim so they should know."



In Florida if you could even get Medicaid on the phone they are rude and hard to deal with.I stopped trying to accomplish anything with a 3 way call to Medicaid with client on phone after being told point blank a couple of times they won't talk about the case with me on the phone.


In your scenario 2 does this apply to medicare covered services that are not covered by medicaid because in Florida ( before the recent reform anyway )medicaid would only pay part c claims if it is a service covered by medicare and medicaid

http://ahca.myflorida.com/Medicaid/pdffiles/2012-2013_Summary_of_Services_Final_121031.pdf pages 39-41


MEDICARE PART C CROSSOVER CLAIMS
Medicaid reimburses for deductibles, coinsurances and
copayments up to the Medicaid fee, less any amounts paid
for QMB, QMB Plus and other Full Benefits Dual Eligible
recipients.
Medicaid reimbursement for Part C claims is limited to those
services in which:
• The Medicare service is also a covered service under
the Medicaid State Plan;
• The Medicare provider is also a Medicaid provider;
and
• The amount specified in the Medicaid State Plan is
greater than the Medicare payment amount.
Medicare Part C claims require the Medicaid Part C Crossover

 

[Josh]

The thing is, about calling Medicaid, you don't need the client. You're calling to ask about a claims practice, not anyone specific.

If it's not covered by Medicaid, then it's no dice.