Wiki Medicaid requirements for non-contracted specialty practice

[em.c.andrews77]

I work for a reproductive medicine/fertility clinic in the state of Oregon. We are not contracted with Medicare or Medicaid. Most of the services we provide here are not covered by these plans (fertility testing, artificial insemination, and in vitro fertilization). I understand that for patients who present to us with Oregon Medicaid, we must have them sign a waiver prior to any non-covered services in order to collect from them and we are required to send claims for all services regardless of whether they are covered expenses. I'm having trouble finding what our requirements might be if we see a patient with Medicaid from another state. For example, we do see a substantial amount of patients from Washington, and occasionally will get a Washington Medicaid patient. Should this be treated the same as our Oregon Medicaid patients? I'm unable to locate a Washington DSHS waiver. Also since the services provided at are clinic are 95% elective services, are there any exceptions to these rules for our type of office? Any information on this would be super helpful! Thanks!

Emily

 

[MarcusM]

I would have some type ABN like CMS requires for non covered services and would beef it up to cover all insurance plans...something to the effect that the patient is responsible for all services provided regardless of insurance. Insurance MAY cover some services, but the patient is still responsible for all services, and have this signed by patient, responsible party, dated and witnessed by staff or manager so this becomes a legal obligation of the patient to the provider.

 

[em.c.andrews77]

Thanks, Marcus. I wondered about that myself--whether a "customized waiver" created by our office would suffice as acceptable by Medicaid programs if they requested proof that the patient signed a waiver (which they have the right to do if the patient indicates to them they were required to pay out of pocket for services).

Also since most Medicaid plans are managed care and require referrals, is this required if the patient is choosing to see a non-PAR provider? There are certainly some services we provide that could be eligible for Medicaid payment, such as early pregnancy monitoring and other reproductive issues, which might result in a denial if a referral is not in place. We only have a handful of Medicaid patients, but I'm trying to establish an effective protocol for all these variables. Any other insight from anyone working in a similar field or circumstance would be greatly appreciated!