Optometry Coding & Billing Alert

Question: I have a patient who has Medicare primary and Medicaid secondary. When I submit a claim for this patient to Medicaid, the denial states the primary payer has paid more than Medicaid would have, and no reimbursement is due. I don't get paid for any deductibles, coinsurance, or balances for this patient. Can this be correct?


Maryland Subscriber

Answer: Unfortunately, this can be correct. Medicaid patients are not responsible for the Medicare deductible or the 20 percent coinsurance when Medicare has paid more than the Medicaid allowable for the service, even though Medicare has only paid 80 percent of their allowable and may have deducted the patient's outstanding deductible from that payment.

But if Medicare has subtracted the patient's deductible from the physician's payment and the total payment is less than Medicaid's allowed charge for the service, Medicaid should pay that portion of the deductible up to the Medicaid allowable amount.

Some variations of Medicaid, such as state Medicaid expansion programs for children or low-income working families, and some Medicaid managed-care programs have a "patient share of cost" in which the patient has a small payment responsibility.

To find out if a patient share of cost applies, and how it works, ask the carrier's provider relations department.