# Question about Medicaid Replacement HMO



## mauadajar (Aug 31, 2015)

Hello. We recently saw an 88 y.o. Pt. She gave us a Medicare card and we saw her for the day of the visit. When it was time for me to drop the claim. I noticed that our EMR alerted us that Pt has a replacement Medicaid hmo. To make it short, Pt has a dual eligible Medicare replacement HMO. Pt was not aware of the change. We could not get an authorization from Humana because they said that we should ask for a PCP referral first. Pt has never seen her assigned PCP before, so they refused to give one. The PCP who referred her to us, refused to give us a referral as well. They said that they will not get paid either.

We are in-network with Regular Medicare, but not with Humana replacement Medicare. Can we bill the Pt? I plan to bill her the full amount, then ask her to coordinate with HumanaMedicare and ask them to reconsider. Is this a violation? 

If Humana refuses, I plan to match what Medicare charges and charge the discounted bill to the Pt. Is this legal? Please advise. I am very new to billing. Thank you.


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## thomas7331 (Sep 1, 2015)

I'm not a legal expert, but my understanding is that if your practice sees a patient in a managed Medicare plan, then by doing so 'deemed acceptance' of the terms of that plan has occurred, and you are required to adhere to the terms even if you are not in the network.  You might claim an exception if you can prove that you were unaware that the patient was enrolled in the plan, but if your EMR has alerted you to the fact that the patient was enrolled, then I think it would be difficult to argue that.   From my own experience in these situations, I'd recommend avoiding a fight with the insurance and the negative customer service to the patient and would not bill this to the member - better to use it as an education tool for the registration staff and make sure that a patient's eligibility is verified before services are rendered.


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## mauadajar (Sep 3, 2015)

thomas7331 said:


> I'm not a legal expert, but my understanding is that if your practice sees a patient in a managed Medicare plan, then by doing so 'deemed acceptance' of the terms of that plan has occurred, and you are required to adhere to the terms even if you are not in the network.  You might claim an exception if you can prove that you were unaware that the patient was enrolled in the plan, but if your EMR has alerted you to the fact that the patient was enrolled, then I think it would be difficult to argue that.   From my own experience in these situations, I'd recommend avoiding a fight with the insurance and the negative customer service to the patient and would not bill this to the member - better to use it as an education tool for the registration staff and make sure that a patient's eligibility is verified before services are rendered.



Thank you so much. Our provider said the same thing. The biller in our office suggested to bill the Pt first. I feel uneasy about billing the old lady and fighting with Medicaid, especially we are in network with the Regular one. Thanks again for your advice.


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## lucretiab (Sep 16, 2015)

Hi 
You can bill the Humana Gold and you will only bill them the amount that they say the patient owes. They are paying you according to the Medicare rates and guidelines. This is the experience that I have had as a biller working Medicare and Medicare replacement plans. Any other questions email me lucretiab@outlook.com.

Hope this helped


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