In Network, Out of Network, Will Accept

[agentjhc]

I am working SNP Duals right now and working on certifications for AEP. I have been surfing the net about plans, etc

Something that is coming up with the UHC Duals is a provider not listed as in network on website but Doc office says they will accept the plan.

Does that mean patient is good to go with the doc without issue for the patient?

Perhaps a dumb question as it seems obvious on the surface that it is, I guess I don't won't any "surprises" for the clients.

 

[WCMason]

I am working SNP Duals right now and working on certifications for AEP. I have been surfing the net about plans, etc Something that is coming up with the UHC Duals is a provider not listed as in network on website but Doc office says they will accept the plan. Does that mean patient is good to go with the doc without issue for the patient? Perhaps a dumb question as it seems obvious on the surface that it is, I guess I don't won't any "surprises" for the clients.

Carrier websites often aren't current so you can't fully trust that information. Doctors offices often don't give accurate information so you can't fully trust that, either.

 

[agentjhc]

That is what I am finding out....and the clients/members caught in the middle....along with the agent!

 

[csyjnapapa]

and all of that at a reduced commission rate!

 

[Josh]

In most states (if not all), a provider contracted with Medicaid can't balance bill a patient with a dual plan, so even if the MA doesn't cover it, the provider has to take the Medicaid payment and be done with it. On the other hand, if they are non-par with Medicaid and it's only going to a UHC provider then all bets are off there.

Websites are often not accurate, the provider generally knows if they're contracted or not and you can always call the carrier which is usually what will give you the most updated information.

 

[agentjhc]

In most states (if not all), a provider contracted with Medicaid can't balance bill a patient with a dual plan, so even if the MA doesn't cover it, the provider has to take the Medicaid payment and be done with it. On the other hand, if they are non-par with Medicaid and it's only going to a UHC provider then all bets are off there.

Websites are often not accurate, the provider generally knows if they're contracted or not and you can always call the carrier which is usually what will give you the most updated information.

Ah!


Josh, what parameters do you use when building a mailing list for MAPD Duals.

 

[GreenSky]

Ah!


Josh, what parameters do you use when building a mailing list for MAPD Duals.

What Josh wrote makes no sense. If a provider is not part of the HMO I don't see where Medicaid will pay.

The bottom line is if someone is in a SNP then they need to see network providers. Period.

I've done extensive mailings for duals. Send me your info via email (below), NOT a PM, and I'll give you a call.

Rick

 

[wehotex]

No, do not trust the office staff to give you the correct information. You might be better off if you spoke with someone in Billing. UHC has MANY different types of insurances, so you must narrow it down to the specific one that you're selling. Ex: some may bill retiree UHC, but not the regular UHC Dual. Ask Ask Ask. It gets easier as you ask your members which specialists they are able to see successfully.

 

[Josh]

What Josh wrote makes no sense. If a provider is not part of the HMO I don't see where Medicaid will pay.

The bottom line is if someone is in a SNP then they need to see network providers. Period.

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.

 

[Chazm]

What Josh wrote makes no sense. If a provider is not part of the HMO I don't see where Medicaid will pay. The bottom line is if someone is in a SNP then they need to see network providers. Period. I've done extensive mailings for duals. Send me your info via email (below), NOT a PM, and I'll give you a call. Rick

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