Wiki Medicaid patients having private insurance

[cghanbari]

I manage a practice in Texas. We accept Medicaid patients. There are 4 care managed organization in Texas. We have a problem with Medicaid patients not revieling to us that they also have private insurance. Mose of the time it shows up on the Texas Medicaid website if they do, however we have had patients that show they don't have any private insurance and we bill Medicaid through their pregnancy and get paid. But then sometimes it shows up 6 months later on the Medicaid website that they had private insurance. In that case we should bill the private insurance first. We recently just received a recoupment for a delivery and all the visits from superior Medicaid for visits in 2013. Over $2000.00. I know they did not show they had private insurance because we check the Texas Medicaid website on each visit and print a copy and attach it to the superb ill. The patients don't tell us if they have private insurance or under their parents policies. But Medicaid will recoup and it is not fair to the provider. My question is this. Is they a search or website that will tell us if a patient has additional policies. How does Medicaid find out if the patient does not tell them they have a private policy they are covered under??? Help. I am so frustrated.

 

[ljm1000]

Hi,

I am a Medicaid Biller for a large Shared Services Center. You asked how Medicaid programs find out about private insurance? In this region some states use a service called HMS. HMS contracts to "scrape" past records and will find evidence if the patient had previous insurance coverage. If they find that evidence it is my understanding that they recoup the Medicaid money paid for the state involved.

It can take time for state programs to amend their records. The primary person responsible for reporting insurance coverage is the patient but they often do not and there is no intent to harm the state or provider at all. it is often normal human forgetfulness. Some of my state programs allow us to call to report a change in Third Party Liability (TPL) and amend their records from our report. Some take changes only from the patient.

Many times I see some evidence of prior non-Medicaid insurance and go ahead and bill for the denial. It adds time to the reimbursement but goes far to ensure the reimbursement is correct and will not be recouped for TPL suspect. JM

 

[cghanbari]

I appreciate your response however it is unfair to the provider that they have provided services and then the money is recoup two years later Yes I understand that patients forget or don't understand how the insurance process works but if the insurance companies like Medicaid are able to do searches on patients to make sure that they don't have any other medical coverage then why can't the provider have the same access so that I can Bill properly and then not having to worry about a recoup. If for instance the patient is issued Medicaid and they come to our office and we check the Medicaid website TMHP doesn't show that they are under any private policy and within months down the road. It shows up on the Medicaid website that they have private insurance now I can't bill a private insurance because some of the private insurance only allows three month the bill so I've lost money. I just want the same opportunity to check each patient that is Medicaid out to make sure that they don't have any private insurance policy they are under.

 

[chornbuckle]

You know the three month filing limit for your private payers applies to the date of the recoup also. You just have to show proof of the date of the recoup when you file the claim to the private payer. It may take an additional call to the insurance company if they deny at first but it will get paid. I have ran into this issue many times.