RE: Non-Par Medicaid and Medicare w/ Medicaid secondary - problems in Hospital Call/Care?

November 19, 2008

We dropped Medicaid in June. The

amount of money and emotions we have saved by not having to deal with them has

been the best thing we ever did. In regards to your questions:

We

dropped all Medi-Cal patients, including Medi-medi patients.

Fortunately for us, the other doctor in the office still sees Medi-medi

because he does hospital backup call. He picked up most of the

medi-medi patients. The straight Medi-Cal patients were referred to

the county health dept. We kept the patients that had Medi-Cal as a

backup to commercial insurance, because we’re required to take the

contracted rate for commercial insurance. I think this only applied

to 2 patients, both of whom have an HMO with $0 copay, so there is not a

balance that would have been picked up by Medi-Cal anyways).

Steve

doesn’t cover call at the hospital, so this is a non-issue for

us. You should check your hospital bylaws and see what they will

require of you. It does appear based on what you quoted in the

statute that you would have to see them and that you aren’t able to

bill the patient directly. I would suspect that this applies to your

office patients also.

You might consider continuing to see those

patients in the hospital, and just know that you will not get paid for your

services. Sort of a good will gesture for your community.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

Roy Medical Associates, Inc.

From: [mailto: ] On Behalf Of Locke

Sent: Wednesday, November 19, 2008

2:23 PM

To: Locke

Subject:

Non-Par Medicaid and Medicare w/ Medicaid secondary - problems in Hospital

Call/Care?

I 've about had it with Medicaid.

I can't seem to get the billing correct to get paid from the state --

which might say more about me than the Medicaid system, but....

I'm curious about 2 issues if I drop Medicaid...

1. How does that work when a patient has Medicaid as a secondary? I have

a few patients with Medicare and Medicaid as secondary -- of course,

many on the list have talked about what a PITA this is -- each

insurance claiming the other is responsible -- but separate from that, how does

it work for the patient if I don't take Medicaid -- do they pay me whatever

Medicaid would have paid me anyway?

2. I cover call at the hospital -- if I don't take Medicaid -- how does

that work for patients I admit as unattached but have Medicaid

-- can I not bill the patient for those services?

Based on some past research, it appears that I can't bill

the patient -- possibly could bill Medicaid regardless of Non-Par

status, but not completely clear.

How are those of you not taking Medicaid, but occasionally having

to see these patient, dealing with this quandry?

Here is the past research on billing Medicaid patients directly -- it

basically says you can't.

http://www.chcpf.state.co.us/HCPF/msb/msbdeptprogramrules.asp

http://www.sos.state.co.us/CCR/Rule.do?deptID=7 & deptName=2505,1305%20Department%20of%20Health%20Care%20Policy%20and%20Financing & agencyID=69 & agencyName=2505%20Medical%20Services%20Boar & ccrDocID=2917 & ccrDocName=10%20CCR%202505-10%208.000%20MEDICAL%20ASSISTANCE%20-%20SECTION%208.000 & subDocID=36453 & subDocName=8.012%20%20PROVIDERS%20PROHIBITED%20FROM%20COLLECTING%20PAYMENT%20FROM%20RECIPIENTS & version=7

8.012 PROVIDERS PROHIBITED FROM COLLECTING PAYMENT

FROM RECIPIENTS

1222996

8.012.1 DEFINITIONS

1222997

8.012.1.A. Providers,

for the purposes of

this section 8.012,

means any person, group or entity that renders services or provides items to

a medical assistance recipient, regardless whether the person,

group or entity is enrolled in the Colorado

medical assistance program,

excluding long-term care facilities licensed pursuant to Section 25-3-101,

C.R.S. Section 25-3-101, C.R.S. is incorporated herein by reference. No

amendments or later editions are incorporated. Copies are available for

inspection from the following person at the following address: Custodian of Records,

Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver,

Colorado 80203-1714.

Any material that has been incorporated by reference in this rule may be

examined at any state publications repository library. [Eff 12/31/2006]

1222998

8.012.1.B. Claim for Penalty means the documented

notification by a recipient or estate of a recipient that a Provider

collected or attempted to collect payment from the recipient for medical

assistance covered items or services. [Eff

12/31/2006]

1222999

8.012.2 PROVIDER LIABILITY

1223000

8.012.2.A. Providers

are explicitly prohibited from collecting payment, or attempting to collect

payment through a third party, from a recipient or the estate of the

recipient for the cost or the cost remaining after payment by Medicaid,

Medicare, or a private insurer of Medicaid covered items or services rendered

to Medicaid recipients. [Eff

12/31/2006]

1223001

8.012.2.B. Providers shall be liable to a recipient or the

estate of the recipient if the Provider knowingly receives or seeks

collections through a third party of an amount in payment for Medicaid

covered items or services. [Eff

12/31/2006]

1223002

8.012.2.C. Providers

are prohibited from collecting, or attempting to collect, payment from recipients for Medicaid

covered items or services regardless of whether Medicaid has

actually reimbursed the Provider and regardless

of whether the Provider is enrolled in the Colorado medical assistance program.

[Eff 12/31/2006]

1223003

8.012.2.D. Providers shall be liable for the amount

unlawfully received, statutory interest on the amount received from the date

of receipt until the date of repayment, plus a civil monetary penalty equal

to one half of the amount unlawfully received. [Eff 12/31/2006]

1223004

8.012.3 RECIPIENT CLAIMS

1223005

8.012.3.A. To establish a Claim for Penalty, a recipient or

the estate of a recipient shall forward a written notice of Claim for Penalty

to the Department and to the Provider within one hundred and twenty (120)

calendar days from the date the Provider unlawfully received payment from the

recipient. Department correspondence shall be sent to Program Integrity, 1570

Grant Street, Denver, CO 80203. [Eff

12/31/2006]

1223006

8.012.3.B. The Claim for Penalty shall establish Provider

liability to the recipient or estate of the recipient for repayment of the

amount unlawfully collected plus interest and a civil penalty equal to

one-half the repayment [Eff 12/31/2006]

1223007

8.012.3.C. The notice of Claim for Penalty shall be a

written document submitted by a recipient or estate of the recipient to the

Department and the Provider describing (1) what Medicaid covered items or

services were rendered, (2) how much money the Provider collected from the

recipient or the estate of the recipient for those covered items or services

and (3) dates of service the items or services were rendered. [Eff 12/31/2006]

1223008

8.012.3.D. The written notice of Claim for Penalty from the

recipient or the estate of the recipient shall be legible and include

detailed documents to substantiate the Claim for Penalty that payment was

given to and unlawfully received by the Provider. [Eff 12/31/2006]

1223009

1. Detailed documents to substantiate the Claim for Penalty

may include but are not limited to credit card receipts, cash receipts or

documentation of processed checks. [Eff

12/31/2006]

1223010

2. The recipient or estate of the recipient is responsible

for providing supporting documentation at the same time the notice of Claim

for Penalty is sent to the Department. [Eff

12/31/2006]

1223011

3. Claim for Penalty sent to the Department must include

written documentation showing that notice of the Claim for Penalty was sent

to the Provider. [Eff 12/31/2006]

1223012

4. Documentation showing the Claim for Penalty was sent to

the Provider may include but is not limited to copies of the certified mail

signature card, post office return receipt, courier service confirmation of

delivery, signature of receipt by the Provider or representative of the

Provider’s office or successful transmission report from a facsimile. [Eff 12/31/2006]

1223013

5. The Department may request additional information from

the recipient or the estate of the recipient. It shall be the responsibility

of the recipient or the estate of the recipient to satisfy the

Department’s requests for information within ten (10) calendar days

from the date of request for the Claim for Penalty to be evaluated by the

Department. [Eff 12/31/2006]

1223014

6. The Department shall review the Claim for Penalty and

documents substantiating the Claim for Penalty submitted by the recipient or

the estate of the recipient. [Eff

12/31/2006]

1223015

7. Any notice of Claim for Penalty that is not legible or

is submitted without documents to substantiate that payment was made to and

unlawfully received by the Provider shall be considered unfounded and shall

be dismissed by the Department. [Eff

12/31/2006]

1223016

8.012.4 PROVIDER RESPONSE

1223017

8.012.4.A. Within ten (10) calendar days from the date of

the recipient’s written Claim for Penalty, the Provider named in the

recipient’s Claim for Penalty shall present the Department with either

a signed written position statement with supporting documentation pertaining

to the recipient’s Claim for Penalty, or a signed written request for a

telephone conference in which to be heard. [Eff

12/31/2006]

1223018

1. The written position statement with supporting

documentation or the signed written request for a telephone conference shall

be sent via certified mail, return receipt or FedEx/UPS so there is no

dispute that Program Integrity, 1570 Grant Street, Denver, CO 80203 received

them. [Eff 12/31/2006]

1223019

8.012.4.B. Provider requests for a telephone conference or

signed written position statements received after ten (10) calendar days from

the date of the recipient’s or the estate of the recipient’s

Claim for Penalty, or failure to respond shall be considered a waiver of the

Provider’s right to be heard and the Claim for Penalty shall be found

in the recipient’s favor. [Eff

12/31/2006]

1223020

8.012.4.C. The Department shall determine whether the Claim

for Penalty has been substantiated and shall send the recipient and the

Provider named in the Claim for Penalty a written determination within thirty

(30) calendar days from the date of the recipient’s or the estate of

the recipient’s Claim for Penalty. [Eff

12/31/2006]

Locke, MD

November 19, 2008