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Re: Non-Medicaid Provider and Medicare Deductible
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Steve Verno
Re: Non-Medicaid Provider and Medicare Deductible
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Apr 26 07 8:25 AM
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Here is your first problem.
Per Florida law, in order to treat a Medicaid patient, the provider must be enrolled with Medicaid as a Medicaid Provider. It doesn't matter if the patient has Medicaid as Primary or Secondary. If the provider is not a Medicaid provider, and the patient presents themselves with any insurance that is primary and Medicaid as secondary, then the provider must inform the patient that he cannot treat that patient because he is not a Medicaid provider.
Florida Statute 409.907:
The agency may make payments for medical assistance and related services rendered to Medicaid recipients only to an individual or entity who has a provider agreement in effect with the agency, who is performing services or supplying goods in accordance with federal, state, and local law, and who agrees that no person shall, on the grounds of handicap, race, color, or national origin, or for any other reason, be subjected to discrimination under any program or activity for which the provider receives payment from the agency.
Per Page 2-2 of the Florida Medicaid Provider Manual:
To receive Medicaid reimbursement, a provider must be enrolled in Medicaid and meet all provider requirements at the time the service is rendered. Every entity that provides Medicaid services to recipients or billing services of any
kind to Medicaid providers must enroll as a Medicaid provider.
Per Page 2-20 of the Florida Medicaid Provider Manual:
Medicaid does not enroll provider applicants who want to bill Medicaid only for the coinsurance and deductible (crossover) portion of a Medicare claim.
On Page 4-5 of the Florida Medicaid Provider Manual:
A provider must be enrolled as a Medicaid provider in order to submit Medicare crossover claims. When enrolling in the Medicaid program, providers must include their Medicare provider number on the Provider Enrollment Application.
As you can see, as a non-Medicaid provider, your doctor cannot provide services to a Medicaid patient, even if the patient has Medicaid as secondary coverage. If you tried to send a claim, it would be denied and Medicaid could investigate your provider as to why he is treating Medicaid patients as a non-Medicaid provider.
In regards to Medicare and Medicaid:
Per Florida Statute 409.908 (13)(c):
Medicaid will pay no portion of Medicare deductibles and coinsurance when payment that Medicare has made for the service equals or exceeds what Medicaid would have paid if it had been the sole payor. The combined payment of Medicare and Medicaid shall not exceed the amount Medicaid would have paid had it been the sole payor. The Legislature finds that there has been confusion regarding the reimbursement for services rendered to dually eligible Medicare beneficiaries. Accordingly, the Legislature clarifies that it has always been the intent of the Legislature before and after 1991 that,
in reimbursing in accordance with fees established by Title XVIII for premiums, deductibles, and coinsurance for Medicare services rendered by physicians to Medicaid eligible persons, physicians be reimbursed at the lesser of the amount billed by the physician or the Medicaid maximum allowable fee established by the Agency for Health Care Administration, as is permitted by federal law.
It has never been the intent of the Legislature with regard to such services rendered by physicians that Medicaid be required to provide any payment for deductibles, coinsurance, or copayments for Medicare cost sharing, or any expenses incurred relating thereto, in excess of the payment amount provided for under the State Medicaid plan for such service.
This payment methodology is applicable even in those situations in which the payment for Medicare cost sharing for a qualified Medicare beneficiary with respect to an item or service is reduced or eliminated. This expression of the Legislature is in clarification of existing law and shall apply to payment for, and with respect to provider agreements with respect to, items or services furnished on or after the effective date of this act. This paragraph applies to payment by Medicaid for items and services furnished before the effective date of this act if such payment is the subject of a lawsuit that is based on the provisions of this section, and that is pending as of, or is initiated after, the effective date of this act.
On Page 3-25 of the Florida Medicaid Provider Manual:
Qualified Medicare Beneficiary (QMB) entitles low-income individuals to have Medicaid pay for their Medicare premiums, deductibles and coinsurance. An individual can have QMB only coverage or QMB coverage and full Medicaid coverage. Recipients who are only eligible for QMB coverage are not eligible for any other Medicaid benefits.
Page 4-3:
Medicare crossover claims are claims that have been approved for payment by Medicare and sent to Medicaid for payment towards the Medicare deductible and coinsurance within Medicaid program limits.
If the provider was enrolled with Medicaid and sent the claim to Medicaid with the EOB, then per Page 4-9 of the Medicaid Provider Manual, Medicaid would subtract Medicares payment from the Medicaid fee. If the remainder is negative, Medicaid will not pay the crossover claim. If the remainder is positive, Medicaid can pay the deductible and coinsurance up to Medicaids maximum fee, per the fee schedule, minus the Medicaid copayment.
Your provider should begin asking all patients who present with insurance other than Medicaid as to whether they have Medicaid as a secondary coverage. This should be done via an insurance affidavit form which is in the Forms Section of this forum. If they say no to Medicaid as secondary, then no problemo. If the patient says yes to Medicaid in any way, shape or form, then the patient must be told to seek care from a Medicaid provider. Either that or the provider enrolls with Medicaid, but even if the provider enrolls, he cannot treat a Medicaid patient until he receives confirmation that he is now a Medicaid provider and he will be issued an effective date.
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Help Wanted - Billing and Coding
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Medical Coding and Billing News
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General Medical Coding Forum
CPT Coding Questions
HCPCS Coding Questions
ICD-9-CM Coding Questions
Evaluation & Management Coding Questions
Acupuncture Billing and Coding
Ambulance Coding and Billing
Cardiology Coding and Billing
Chiropractic Coding and Billing
Dental Billing and Coding
DME Coding and Billing
Emergency Department Coding and Billing
Family Practice Coding and Billing
Hospital Inpatient and Outpatient Coding
Hospital Billing, Appeals and Collections
Internal Medicine Coding and Billing
Laboratory Coding and Billing
Ophthalmology Coding and Billing
OB-GYN Coding and Billing
Pain Management Coding and Billing
Pediatric Coding and Billing
Podiatry Coding and Billing
Physical Therapy Coding and Billing
Psychiatry Coding and Billing
Radiology Coding and Billing
Surgery Coding and Billing
Neurology Coding and Billing
Urgent Care Coding and Billing
Provider Compliance
Billing Center Compliance
HIPAA
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