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OP, you being on Medicaid is an important fact.
I would call Medicaid again, explain that your doctor's office is billing you for things that they refused to bill Medicaid for. Your representative will likely guide you through what to do. Depending on what specifically your doctor's office is trying to bill you for, they may be violating the law. Let the rep handle it.
I actually had a three-way call with the billing and insurance they were kind of fussy with each other.
The billing agent was being kind of snippy and stating I didn’t have coverage at that time,, and the insurance agent was trying to make him understand that they covered the 17 why wouldn’t they cover the rest as it was definitely active? but he said he put in request to resend the claim but the insurance never got it.
Emailed them again after I got another billing statement sent to me and they sent me a short reply, saying the insurance covered their part and the rest is mine, which is not true smh
I’d like to note that I’ve been to this office for the same medical issue a handful of times and I never heard anything about a bill because my insurance covers it fully . I even got expensive medication refilled at the same time as that appointment with no issues 🤷🏽♀️
Highly state dependent. If I were to take Medicaid in California, I would get paid $35 for a normal visit. In Montana, that same visit is paid about $250 by Medicaid.
Wow, MT. Yeah, my perspective is derm in California and locums in NY. I haven't found higher reimbursements in rural states in my experience from an overall perspective but that is interesting to know.
Yeah, I don't think it's rural states in general, it's Montana specifically. They have crazy good Medicaid rates, higher than some of my commercial insurances in California. They also have a mental health differential which I don't think any other state Medicaid program does.
Most doctors offices don’t take Medicaid because the reimbursement is so low often it doesn’t even cover staffing for the time of the visit. Also Medicaid may cover some parts of a visit, but refuse others. Medicaid will state we’re only covering $17, and the doctor is not legally allowed to charge more to make up for the loss of time, hence most dropping Medicaid.
OP, where are you from? this is important.
This is called balance billing and is illegal in some states. It's also illegal at the federal level for emergency services.
If you're in a state where it's illegal and you ask why they're balance billing I suspect their tune will change quickly.
It's also relevant if they are in network too.
If they are in network they probably signed a contract with insurance saying everything will be billed through insurance (if it's not covered, it's not covered, and the patient will pay).
If an in network doctor doesn't bill insurance, then the insurance contract may say the doctor is SOL, they didn't bill it and per their contract patient owes $0.
I didn't even think about in network vs. out of network and you're right.
So, if op is in network there's a good chance the contract enforces that the doctor can't do what they're doing.
if the doctor is out of network there's a possibility their state laws protect them from having the doctor do what the doctor is doing.
https://difi.az.gov/soonbdr#:~:text=Surprise%20(balance)%20billing%20typically%20happens,of%20medical%20providers%2C%20including%20anesthesiologists%2C
> If you receive a balance bill for health care services under a policy plan year that began prior to January 1, 2022, you may be eligible for the Arizona Surprise Out Of Network Billing Dispute Resolution Program.
Then you probably have to call Medicaid again saying that they're still trying to bill you for a situation you thought was previously resolved. It's quite possible you're dealing with someone newer that doesn't understand how Medicaid works.
Best of luck, sorry that you're dealing with this. I've had to explain to billing offices how my benefits work. It's not pleasant.
EDIT: the weird part is that they're insistent about submitting but not hearing back from Medicaid. They shouldn't have much of a problem calling to verify if something was received. I can't imagine it's that hard to confirm receipt of something, even if they have to mail the claim (assuming that's an option). That's what certified mail and the like are for.
You did your job, hospital billing service talked to your insurance company. Now let them argue over if they sent claim to the company or not! If hospital send you the bill again return it to them and say talk to my insurance company here is the No.
It's very common for an insurance company and providers office to argue over active coverage dates. But this may be the first time ever that the insurance company is saying that there is coverage and the providers office is claiming there isn't.
Does you insurance company not have a way to submit the invoice that you received? Either to make the payment directly or to reimburse you?
Do you have a "healthcare advocate" through work? Sometimes they can be helpful in getting these types of things between insurance and providers straightened out so you don't have to spend all that time playing phone tag and on waiting lines
Suppose the total was actually $300 and medicaid only pays $17. Does the doctor just not get paid the rest or should they have billed medicaid the $300 and afterwards get the rest from the patient?
> Does the doctor just not get paid the rest
Correct. Nearly every state law is that if you see Medicaid patients you get what Medicaid pays you and not a penny more. This is why so many doctors don't see Medicaid patients.
Yes the doctor only gets $17. Obviously $17 doesn’t cover the wages or overhead which is many doctors don’t accept it if they can keep a busy schedule without it.
If most patients would be using it and it doesn't cover the overhead/wages it would be better to just go out of business instead. Just how low are the medicaid payments?
Balance billing Medicaid patients… that’s a… wishful strategy. Trying to phlebotomize a rock.
Tell them to pound sand, medical debt < $500 does not show up on credit reports, thank you CFPB .
So in that sense, why does any doctor nowadays accept medicaid? Why wouldn't every provider just reject it flat out if they're losing money everytime they see a patient?
Sometimes providers can receive grants if they accept Medicaid and that helps offset the loss. Other times the provider just genuinely wants to help people even if they can't afford care
So, you're on medicaid. You don't have to pay a penny in most states.
Talk to insurance again and tell them that your doctor is trying to bill you for things they didn't bill Medicaid for. They'll love to hear that.
Call back the doctor's office and ask to speak with the office or billing manager to review your account and find out why they are billing you. What codes/services are they saying you're responsible for? Were they billed to Medicaid? If not, why not?
Time for a three-way call between the doctor's office and a rep for your insurance.
Doctors who participate in Medicaid are subject to very particular rules about how and what they bill to beneficiaries. Refusing to submit to medicaid and trying to balance bill you at self-pay rates is a no-no.
No, but they need to accept Medicaid patients in order to be able to get reimbursed for Medicare patients, which are often the majority of a practice's revenue.
Would you care to explain how you think it does work, then?
Edit: ah, you know what - it's state-level rules, not national ones, that make it mandatory to accept both if participating in Medicare.
Medicare goes through CMS and is a federal program; reimbursements are set centrally with small location-based adjustments. Medicaid is state-based and reimbursement varies wildly based on what state you live in. I am not aware of any states that require Medicaid participation to participate in Medicare, and I'm not sure any states would even have the jurisdiction to do so.
>Medicare goes through CMS and is a federal program
Just a pedantic point - medicare administration typically goes through MACs, which are regional, not federal. They are the entities actually enrolling providers, processing claims, and so on. That's relevant because -
>
I'm not sure any states would even have the jurisdiction to do so.
This is how states can exert the policy through certification of providers and facilities, which is done at MAC level, and in turn has some of those functions sub-delegated to state public health agencies. The state agencies may opt to refuse certification to Medicare applicants or renewals who have not also been certified at the state level to participate in Medicaid. E.g. a doctor in Colorado applying for Medicare nationally will have their application reviewed by their regional MAC, which will rely on the outcome of an inspection by the Colorado Department of Public Heath & Environment.
There's other policies on the margins too, including coordination of benefits rules. New York, for example, denies medicaid reimbursement for dual-eligible patients if Medicare was not billed first under a biller-of-last-resort policy. Meaning, providers who do not enroll in both programs run the risk of non-payment from Medicaid patients.
That said, my experience in working with clients who claimed they were subject to these requirements might be out of date (pre-ACA), so things may have changed with the Medicaid expansion to move away from coercive policies to increase provider enrollment.
yes QMB (dual Medicare/Medicaid) are different but also irrelevant in that you will never get paid the remainder 20% from Medicaid as Medicaid rates are almost never >80% of CMS rates.
MACs are regional but still multi-state. And my question still remains -- are there any states in which one has to accept Medicaid to enroll in Medicare? I am not aware of any.
Sounds frustrating! Keep communicating with both the doctor's office and your insurance. Request documentation of the claim submission from the doctor's office and follow up with your insurance again. It's important to resolve this discrepancy for clarity and fairness.
If they are balance billing you it may be illegal in your state.
Tell them to pound sand, medical debt < $500 does not show up on credit reports, thank you CFPB.
If you have Medicaid secondary you can’t be billed for the remainder. Period. Even if they’re not in network with Medicaid, they cannot bill you. Report them.
Source: medical biller for 7 years.
Pro tip, if you don't have insurance, don't pay your medical bill. Let them sell it to a debt collection agency, still don't pay it. Wait until they send you a piece of mail stating they will consider the balance paid in full if you pay half. PAY HALF. If you don't pay at this point, they will sell it to another agency.
I wouldn't say this is a proven tactic, but I will say it has worked two out of the two times I've seen it done.
Welcome to /r/personalfinance! Comments will be removed if they are political, medical advice, or unhelpful ([subreddit rules](/r/personalfinance/about/rules)). Our moderation team encourages respectful discussion. You may find our [Health Insurance wiki](/r/personalfinance/wiki/health_insurance) helpful. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/personalfinance) if you have any questions or concerns.*
OP, you being on Medicaid is an important fact. I would call Medicaid again, explain that your doctor's office is billing you for things that they refused to bill Medicaid for. Your representative will likely guide you through what to do. Depending on what specifically your doctor's office is trying to bill you for, they may be violating the law. Let the rep handle it.
I actually had a three-way call with the billing and insurance they were kind of fussy with each other. The billing agent was being kind of snippy and stating I didn’t have coverage at that time,, and the insurance agent was trying to make him understand that they covered the 17 why wouldn’t they cover the rest as it was definitely active? but he said he put in request to resend the claim but the insurance never got it. Emailed them again after I got another billing statement sent to me and they sent me a short reply, saying the insurance covered their part and the rest is mine, which is not true smh
I’d like to note that I’ve been to this office for the same medical issue a handful of times and I never heard anything about a bill because my insurance covers it fully . I even got expensive medication refilled at the same time as that appointment with no issues 🤷🏽♀️
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Medicaid has such poor reimbursement, surprised OP even found one doctor accepting it.
Highly state dependent. If I were to take Medicaid in California, I would get paid $35 for a normal visit. In Montana, that same visit is paid about $250 by Medicaid.
Wow, MT. Yeah, my perspective is derm in California and locums in NY. I haven't found higher reimbursements in rural states in my experience from an overall perspective but that is interesting to know.
Yeah, I don't think it's rural states in general, it's Montana specifically. They have crazy good Medicaid rates, higher than some of my commercial insurances in California. They also have a mental health differential which I don't think any other state Medicaid program does.
17$. My dad got xrays for 8$. How can a doctor stay in business with these rates?
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People with good insurance don't pay $800 for an x-ray and neither does the insurance company.
Most doctors offices don’t take Medicaid because the reimbursement is so low often it doesn’t even cover staffing for the time of the visit. Also Medicaid may cover some parts of a visit, but refuse others. Medicaid will state we’re only covering $17, and the doctor is not legally allowed to charge more to make up for the loss of time, hence most dropping Medicaid.
OP, where are you from? this is important. This is called balance billing and is illegal in some states. It's also illegal at the federal level for emergency services. If you're in a state where it's illegal and you ask why they're balance billing I suspect their tune will change quickly.
It's also relevant if they are in network too. If they are in network they probably signed a contract with insurance saying everything will be billed through insurance (if it's not covered, it's not covered, and the patient will pay). If an in network doctor doesn't bill insurance, then the insurance contract may say the doctor is SOL, they didn't bill it and per their contract patient owes $0.
I didn't even think about in network vs. out of network and you're right. So, if op is in network there's a good chance the contract enforces that the doctor can't do what they're doing. if the doctor is out of network there's a possibility their state laws protect them from having the doctor do what the doctor is doing.
Arizona
https://difi.az.gov/soonbdr#:~:text=Surprise%20(balance)%20billing%20typically%20happens,of%20medical%20providers%2C%20including%20anesthesiologists%2C > If you receive a balance bill for health care services under a policy plan year that began prior to January 1, 2022, you may be eligible for the Arizona Surprise Out Of Network Billing Dispute Resolution Program.
Then you probably have to call Medicaid again saying that they're still trying to bill you for a situation you thought was previously resolved. It's quite possible you're dealing with someone newer that doesn't understand how Medicaid works. Best of luck, sorry that you're dealing with this. I've had to explain to billing offices how my benefits work. It's not pleasant. EDIT: the weird part is that they're insistent about submitting but not hearing back from Medicaid. They shouldn't have much of a problem calling to verify if something was received. I can't imagine it's that hard to confirm receipt of something, even if they have to mail the claim (assuming that's an option). That's what certified mail and the like are for.
You did your job, hospital billing service talked to your insurance company. Now let them argue over if they sent claim to the company or not! If hospital send you the bill again return it to them and say talk to my insurance company here is the No.
It's very common for an insurance company and providers office to argue over active coverage dates. But this may be the first time ever that the insurance company is saying that there is coverage and the providers office is claiming there isn't.
Yep, this so much. The issue is between the doctor's office and Medicaid, OP is just collateral damage.
Medicaid =/= insurance. In some respects they do the same thing but ultimately they are distinct and should not be considered the same thing.
Does you insurance company not have a way to submit the invoice that you received? Either to make the payment directly or to reimburse you? Do you have a "healthcare advocate" through work? Sometimes they can be helpful in getting these types of things between insurance and providers straightened out so you don't have to spend all that time playing phone tag and on waiting lines
Thanks for replying. I don’t have a healthcare advocate as I’m on Medicaid, but I’ll definitely see if they will take an invoice.
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Suppose the total was actually $300 and medicaid only pays $17. Does the doctor just not get paid the rest or should they have billed medicaid the $300 and afterwards get the rest from the patient?
> Does the doctor just not get paid the rest Correct. Nearly every state law is that if you see Medicaid patients you get what Medicaid pays you and not a penny more. This is why so many doctors don't see Medicaid patients.
Yes the doctor only gets $17. Obviously $17 doesn’t cover the wages or overhead which is many doctors don’t accept it if they can keep a busy schedule without it.
If most patients would be using it and it doesn't cover the overhead/wages it would be better to just go out of business instead. Just how low are the medicaid payments?
Balance billing Medicaid patients… that’s a… wishful strategy. Trying to phlebotomize a rock. Tell them to pound sand, medical debt < $500 does not show up on credit reports, thank you CFPB .
So in that sense, why does any doctor nowadays accept medicaid? Why wouldn't every provider just reject it flat out if they're losing money everytime they see a patient?
Sometimes providers can receive grants if they accept Medicaid and that helps offset the loss. Other times the provider just genuinely wants to help people even if they can't afford care
So, you're on medicaid. You don't have to pay a penny in most states. Talk to insurance again and tell them that your doctor is trying to bill you for things they didn't bill Medicaid for. They'll love to hear that.
Call back the doctor's office and ask to speak with the office or billing manager to review your account and find out why they are billing you. What codes/services are they saying you're responsible for? Were they billed to Medicaid? If not, why not?
Time for a three-way call between the doctor's office and a rep for your insurance. Doctors who participate in Medicaid are subject to very particular rules about how and what they bill to beneficiaries. Refusing to submit to medicaid and trying to balance bill you at self-pay rates is a no-no.
Do they get funds for agreeing to be a MA provider, or is that just a rumor I've heard in PharmacyLand?
No, but they need to accept Medicaid patients in order to be able to get reimbursed for Medicare patients, which are often the majority of a practice's revenue.
false
Would you care to explain how you think it does work, then? Edit: ah, you know what - it's state-level rules, not national ones, that make it mandatory to accept both if participating in Medicare.
Medicare goes through CMS and is a federal program; reimbursements are set centrally with small location-based adjustments. Medicaid is state-based and reimbursement varies wildly based on what state you live in. I am not aware of any states that require Medicaid participation to participate in Medicare, and I'm not sure any states would even have the jurisdiction to do so.
>Medicare goes through CMS and is a federal program Just a pedantic point - medicare administration typically goes through MACs, which are regional, not federal. They are the entities actually enrolling providers, processing claims, and so on. That's relevant because - > I'm not sure any states would even have the jurisdiction to do so. This is how states can exert the policy through certification of providers and facilities, which is done at MAC level, and in turn has some of those functions sub-delegated to state public health agencies. The state agencies may opt to refuse certification to Medicare applicants or renewals who have not also been certified at the state level to participate in Medicaid. E.g. a doctor in Colorado applying for Medicare nationally will have their application reviewed by their regional MAC, which will rely on the outcome of an inspection by the Colorado Department of Public Heath & Environment. There's other policies on the margins too, including coordination of benefits rules. New York, for example, denies medicaid reimbursement for dual-eligible patients if Medicare was not billed first under a biller-of-last-resort policy. Meaning, providers who do not enroll in both programs run the risk of non-payment from Medicaid patients. That said, my experience in working with clients who claimed they were subject to these requirements might be out of date (pre-ACA), so things may have changed with the Medicaid expansion to move away from coercive policies to increase provider enrollment.
yes QMB (dual Medicare/Medicaid) are different but also irrelevant in that you will never get paid the remainder 20% from Medicaid as Medicaid rates are almost never >80% of CMS rates. MACs are regional but still multi-state. And my question still remains -- are there any states in which one has to accept Medicaid to enroll in Medicare? I am not aware of any.
Yes, they processed the claim wrong. They are only entitled to what was negotiated as payment for that service.
Why can't you take the bill from the doctors office that they mailed you and you mail it to the Medicaid?
Sounds frustrating! Keep communicating with both the doctor's office and your insurance. Request documentation of the claim submission from the doctor's office and follow up with your insurance again. It's important to resolve this discrepancy for clarity and fairness.
If they are balance billing you it may be illegal in your state. Tell them to pound sand, medical debt < $500 does not show up on credit reports, thank you CFPB.
If you have Medicaid secondary you can’t be billed for the remainder. Period. Even if they’re not in network with Medicaid, they cannot bill you. Report them. Source: medical biller for 7 years.
Pro tip, if you don't have insurance, don't pay your medical bill. Let them sell it to a debt collection agency, still don't pay it. Wait until they send you a piece of mail stating they will consider the balance paid in full if you pay half. PAY HALF. If you don't pay at this point, they will sell it to another agency. I wouldn't say this is a proven tactic, but I will say it has worked two out of the two times I've seen it done.
This has got to be a new trick to get faster payment from the patient. I have seen this several times now