Wiki Medicare and medicaid patien

[senasekpe]

Hello,
My provider is only credentialled with Medicaid. She now has a patient that has both insurances. My question is: Will Medicaid pays for the service in full as we cannot bill Medicare?
Thanks

 

[thomas7331]

Hello,
My provider is only credentialled with Medicaid. She now has a patient that has both insurances. My question is: Will Medicaid pays for the service in full as we cannot bill Medicare?
Thanks

I think it's very unlikely Medicaid will pay - you may want to contact your state Medicaid's plan administrator and ask them since it's an unusual situation. It's possible they may allow it if your provider has a valid reason for not being able to be enrolled in Medicare. Has your provider opted out of Medicare, or just never enrolled? If it's the latter, then it's a fairly simple process to complete the paperwork and get enrolled so that it won't be a problem for this patient.

 

[amyjph]

The provider has to accept assignment for MCR. It depends on the status of your provider with Medicare I think as well.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf

● All Medicare providers must accept assignment for Part B-covered services furnished to dually eligible beneficiaries. Assignment means the Medicare Physician Fee Schedule amount is payment in full.

 

[senasekpe]

I think it's very unlikely Medicaid will pay - you may want to contact your state Medicaid's plan administrator and ask them since it's an unusual situation. It's possible they may allow it if your provider has a valid reason for not being able to be enrolled in Medicare. Has your provider opted out of Medicare, or just never enrolled? If it's the latter, then it's a fairly simple process to complete the paperwork and get enrolled so that it won't be a problem for this patient.

Thank you! This was very helpful. After enrolling in the Original Medicare does she also have to credential with the private insurance that managed Medicare: like Humana, Aetna...

 

[thomas7331]

Thank you! This was very helpful. After enrolling in the Original Medicare does she also have to credential with the private insurance that managed Medicare: like Humana, Aetna...

It's not a requirement to enroll in the Medicare Advantage plans, but if the provider sees patients from those plans there may be restrictions or limitations on what the plan will allow and pay as an out-of-network provider.

 

[sls314]

Thank you! This was very helpful. After enrolling in the Original Medicare does she also have to credential with the private insurance that managed Medicare: like Humana, Aetna...

It would be helpful, I think, if your provider is willing.

I used to work for a facility that didn't have a contract with Humana Medicare. It was a mess every time we had a dual Medicare/Medicaid patient.

Ohio Medicaid would not pay for anything, because for a dual patient they only paid secondary balances after Medicare. Since Medicare didn't pay, Medicaid wouldn't pay for anything either.

(The only thing we ever got paid for was ER visits. If a patient came in for non-emergency radiology/labs and our registration didn't catch it, we had to eat the cost of the service. We couldn't bill the patient because we didn't provide advance notification that they would be responsible for the charge. Like I said, it was a mess!)