Newborns Without Insurance:
Reimbursement Tips
Published on Thu Oct 01, 1998
When a pediatrician sees a newborn in the hospital, he or she may well not know whether the child has health insurance coverage. If it turns out that there is no insurance, what should your billing department do? And considering that many of these patients may be eligible for or even enrolled in Medicaid, how should you navigate your way through the publicor, in some cases privatesystem?
The Medicaid Dilemma
This is an interesting question, says Cece Fontaine, RN, office manager for L. Fiatoa, MD, a pediatric practice in Honolulu, HI. Were right outside a public housing project, so 98 percent of our patients are on welfare.
Fontaines problem with this is typical of many pediatric practices with a large proportion of Medicaid patients. The pediatrician receives a capitated payment each month for each Medicaid patient, but the parents may not always go to that pediatrician. The mother may not even give birth in a hospital where that pediatrician has privileges. So, the pediatrician who ends up treating the baby, but is not the assigned provider, may need to ask the assigned provider to refer the patient to him or her. Otherwise, the capitated payment will go to the wrong pediatrician.
Many of the patients in Fontaines practice are on Medicaid, but in Hawaii, as in many states, Medicaid patients are being assigned to commercial plans. That means that they can only go to their chosen (or assigned) pediatrician. A lot of us are capitated, says Fontaine, referring to physicians in Hawaii. The patient presents the practice with a card, but it has another pediatricians name on it. If we end up taking care of someone elses patient, we might end up eating the costs.
There is a way to avoid this problem. It takes a little bit of time, but its worth itespecially when you think about how many visits and shots you will be giving during a childs first year of life. Heres what you can do.
The Retroactive Referral
You can try to initiate a referral from the other doctor, says Fontaine. Contact the office of the other pediatrician, and say that you have been seeing this patient. You should do this diplomatically, of course; what you are doing is asking your colleague to hand over his capitation to youincluding the fees from the months during which you have already cared for the baby. But, after all, you are the one who is earning the payments.
Tip: If hospital visits are carved out of the capitation, as they are in Hawaiis Medicaid plans, at least you will be reimbursed for the newborn exam and any care you provided in the hospital.
If [the other practice] is willing and nice, they will write a [...]
