Pediatric Coding Alert

Question: We have recently had an influx of patients (at least one per week) presenting with one parent’s commercial insurance card. Then the claim gets denied, and the parents respond that they decided not to enroll the child on the commercial insurance, but rather enrolled the baby on the other parent’s coverage (Medicaid). However, we don’t accept Medicaid. As a non-participating practice, we will not get paid by Medicaid for seeing these patients, and therefore I would not have seen the baby if I’d known she was on Medicaid. Can we bill the parents in this situation?

Answer: Since you do not participate with Medicaid, you can charge the parents and if they do not pay, you can send the account to collections. In your bill, send a letter notifying the parents that they are responsible for the balance since you were not notified prior to the visit that the child was on Medicaid (with which you do not participate).

If this is happening chronically, then you should start verifying patients’ insurance coverage before the first visit. If you are unable to verify the coverage, you might consider canceling the appointment or charging self-pay prices (which you would refund later if the insurer ends up being valid and paying you).