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Medicaid HMO

Vaida Posted Fri 09th of January, 2015 11:09:21 AM

Hi. I am just wondering if it is legal to bill Medicaid HMO patients (patient has Medica to be exact) for services that were denied for no authorization. Is there a written rule about this? I am aware Medicaid is a payor of last resort, so I want to make sure we are allowed to bill patients in these situations before sending them a bill.

SuperCoder Answered Fri 09th of January, 2015 12:44:59 PM

Thanks for your question. When patient's are covered by Medicaid you are not allowed to bill the patient unless the explanation of benefits instructs you to do so. If this insurance company is related to Medicaid as a HMO plan, it will probably have the same rules regarding billing patients. Your practice should obtain authorizations for patients to ensure that you receive payment on items requiring prior authorization. In some instances, you may be able to obtain a retroactive authorization. This is an option that you may want to consider.

I will need some additional information in order to give you a definitive answer and try to locate a policy on prior authorizations. What state is your practice located in? Also, can you provide any contact information for the Medica insurance?

Vaida Posted Fri 09th of January, 2015 15:02:48 PM

Thank you so much for your response. Our practice is located in Florida. Medica's phone number is 800.348.5548. Thanks again!

SuperCoder Answered Fri 09th of January, 2015 15:59:41 PM

Thanks for the additional information. I have further researched and found a link with the guidance for prior authorization for Medica Healthcare. As stated previously, the liability will be on the provider for submitting claims without obtaining prior authorization. Insurance contracts indicate certain services that require prior authorization and because the provider office failed to obtain this, you are not able to bill the patient. The change with this particular insurance occurred on January 1st 2014. You may appeal the denial within 60 days by submitting information relating to the medical necessity for the service. See the attached link for the policy on prior authorization and utilization management.

https://www.medica.com/providers/policies-and-guidelines/um-policies-and-prior-authorization

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