Dealing with Medicaid Third Party Libility

aethelwulffe wrote on Thursday, July 25, 2013:

Hello All.

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/TPL-COB-Page.html

OK, the least among us have new hoops to jump through. If a family happens to have gotten insurance, but it does not pay anything and the child qualifies for Medicaid, that family and their providers are in quite a twist.

  1. You must bill to the insurance company, get a denial or partial payment.
  2. Submit to Medicaid…If with denial from the other payer, you must do it on their website and upload the denial letter every time.

Here is the first problem. You bill a CPT 90846 code to the TPL party, guess what? You gotta cross-walk to a HCPCS H2019-HR to Medicaid…
This is a big push to require folks to hit up someone else before going to medicaid. Fine. Good idea probably, but their only solution I have seen provided indicates that everything has to be done in the most labor-intensive way possible. Even doing this, in your fee sheet, you need to indicate first that you have billed it to one party, then switch codes somehow before billing to Medicaid. That doesn’t really work in our otherwise straightforward billing system. It is not a “corrected claim” or anything else. Any suggestions as to what this should look like in a finished product?

I am hammering on the Medicaid TPL Goon’s door tomorrow with my buddy to try to find out what the F. If there is no “Oh yeah, you can submit with both sets of codes, we’ll just ignore the others” or some other systemic and simple enabling accommodation, I have to pursue fighting or accommodating this at a different level.
…of course, there are also “plus” or “EM” codes to deal with too now…

fsgl wrote on Sunday, July 28, 2013:

What is the reason why the HCPCS code cannot be submitted initially?

Physician offices use CPT codes primarily but hospitals use the HCPCS codes, therefore the commercial carriers should be able to accept the latter from practitioners as well.

Medicaid claim submissions have been traditionally difficult. In the old days of paper submissions, claims had to be submitted multiple times for very silly denial reasons (the office did not indicated whether the visit was the result of a pregnancy and the patient was male). More often than not, it would cost the practice less money and staff time to just write off the charge than it would be to continue re-submitting the claim. As a result many practices will care for established Medicaid patients but will not accept new Medicaid patients.

Unless the client has a large Medicaid practice or you are quixotic, have a bottle of aspirin at the ready as you wrestle with Florida Medicaid.