[blyons]

If a pt is Medicare prime and Medicaid is secondary, can you obtain an ABN if a MD orders a custom trach tube???? The cost of the tube is 3x the Medicare allowable. We would like to 1) obtain an ABN (upgrade reason)...2) Bill Medicare...which will auto cross to Medicaid and 3) bill the pt for the difference we were not reimbursed for. We are being told we have to accept assignment for dual eligible pts and that you can not balance bill a dual eligible pt. What is everyone doing in the case where the cost of an item exceeds the allowable??????? HELP!!!

[DeeDee]

You need to refer to your state Medicaid guidelines as every state is different.

In some states, you cannot bill the patient for a covered item at all. In others, if you notify a patient, in writing, within certain time periods, you can collect from the patient.

[blyons]

Thanks DeeDee...
Do you have any experience w/NY Medicaid? Even with the references we can find...it still is unclear if we can ABN a pt and expect them to pay. They have said to us that if we bill the primary payor....nothing more than the allowable + subsequent co balance will ever be paid. They said "only IF YOU DO NOT bill the primary and have a written agreement w/ the pt...CAN you Bill the pt" 1) It makes no sense - if we did that the pt would have to forego the allowable from the primary and hence be responsible for the whole amount??? and 2) If it's Medicare - you would HAVE to do an ABN....so what if they select #1? You're right back where you began.....only eligible for the allowable and not able to bill the pt???? Any thoughts???
Thank you!!!!

[DeeDee]

I do not have any experience with NY Medicaid, sorry. I am in Ohio, and Ohio has a similar stance where you can bill the patient with a written agreement; however, it doesn't specify that you cannot bill the primary.

I know its a long shot but have you tried contacting the physician and explaining the circumstance to him/her and letting them know that; unfortunately, you're not going to be able to provide this item to their patient and seeing if there is an alternative that they can order that will be covered at an acceptable reimbursement?

[blyons]

DeeDee,
If Medicare is the primary, do you get an ABN....collect from Medicare...Ohio Medicaid.....then pt?
Thanks for your help.

[DeeDee]

Ohio Medicaid rule 5101:3-1-13.1 states:

Providers are not required to bill the department for Medicaid-covered services rendered to eligible consumers. However, providers may not bill consumers in lieu of the department unless:

1.) The consumer is notified in writing prior to the service being rendered that the provider will not bill the department for the covered service; and

2.) The consumer agrees to be liable for payment of the service and signs a written statement to that effect prior to the service being rendered; and

3.) The provider explains to the consumer that the service is a covered Medicaid service and other Medicaid providers may render the service at no cost to the consumer.

Services that are not covered by the Medicaid program, including services requiring prior authorization that have been denied by the department, may be billed to the consumer when the provisions shown above in 1 and 2 are met.

Unfortunately, we have not used this in a situation similar to yours, we have only used in situations that are Medicaid direct and the patient/family member is wishing to pay for the items.