RE: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay

[Guest guest]

If you are a primary care physician, in NJ, Medicaid HMO is all capitation, no FFS. You must not be a primary care doctor? Or you are not the patients PCP and then you get nothing. I have never seen a patient with more than one Medicaid plan. Not possible. It’s either Amerigroup, Americhoice or Horizon NJ Healthcare. I don’t know why you would waste time billing plans the patient is not in. Don’t you have their card? Or you can check with the phone in line which plan they are on. If you are not their primary, you need a referral. But in NJ, Medicaid does not balance pay what Medicare does not cover unless it’s the deductible and Medicare has paid nothing. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of s9hill5Sent: Tuesday, July 17, 2012 2:14 PMTo: Subject: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay I am in NJ. These patients, Medicaid HMO do not pay me capitation. Americhoice paid 1 pt 1 visit coinsurance $23. Now I try to bill other Medicaid HMO. But Amerigroup denied.Thanks for your input.>> In NJ, if Medicare pays more than Medicaid allowable amount it is considered> paid in full. Medicaid does not pay the balance like a normal secondary> would. However, if it is an HMO, you are receiving capitation which is> usually pretty fair and you can't bill anyway.> > > > Kathy Saradarian, MD> > NJ> > > > Our squirrels do not behave but are needed.> > > > From: > [mailto: ] On Behalf Of s9hill5> Sent: Tuesday, July 17, 2012 1:52 PM> To: > Subject: Medicaid HMO( Amerigroup, Americhoice....)> refuse to pay> > > > > > I have a few pts. They have medicare and Medicaid HMO. Medicare paid most of> the claim ( 99214, $92.64). THere are deductible or coinsurance(99214> $23.16). I sent claims and copies of Medicare EOB to Medicaid HMO. But> Medicaid HMO refused to pay. They stated that they suppose to pay $34.45,> Medicare already paid $92.64, more than Medicaid HMO suppose to pay, so> Medicaid HMO will not pay.> > I was told Medicaid HMO suppose to pay the deductible and coinsurance. > I will appeal. But looks like hopeless. Anybody has this kind of experience?> THanks>

[Guest guest]

Just to chime in....In NJ all Medicaid patients were turfed into one of the four Medicaid HMO's as of 2011. If your INS patient panel is low (less that 100 patients) you are paid FFS, not Capitated. Have similar situation with United Healthcare Communuty Plan (formerly Americhoice) that doesn't want to pick up the tab for 2012 Medicare deductible ($140) beyond their basic office fee of $40-$50. Suggestions?

To: Sent: Tuesday, July 17, 2012 2:20 PMSubject: RE: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay

If you are a primary care physician, in NJ, Medicaid HMO is all capitation, no FFS. You must not be a primary care doctor? Or you are not the patients PCP and then you get nothing. I have never seen a patient with more than one Medicaid plan. Not possible. It’s either Amerigroup, Americhoice or Horizon NJ Healthcare. I don’t know why you would waste time billing plans the patient is not in. Don’t you have their card? Or you can check with the phone in line which plan they are on. If you are not their primary, you need a referral. But in NJ, Medicaid does not balance pay what Medicare does not cover unless it’s the deductible and Medicare has paid nothing.

Kathy Saradarian, MD

NJ

From: [mailto: ] On Behalf Of s9hill5Sent: Tuesday, July 17, 2012 2:14 PMTo: Subject: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay

I am in NJ. These patients, Medicaid HMO do not pay me capitation. Americhoice paid 1 pt 1 visit coinsurance $23. Now I try to bill other Medicaid HMO. But Amerigroup denied.Thanks for your input.>> In NJ, if Medicare pays more than Medicaid allowable amount it is considered> paid in full. Medicaid does not pay the balance like a normal secondary> would. However, if it is an HMO, you are receiving capitation which is> usually pretty fair and you can't bill anyway.> > > > Kathy Saradarian, MD> > NJ> > >

> Our squirrels do not behave but are needed.> > > > From: mailto:%40yahoogroups.com> [mailto:mailto:%40yahoogroups.com] On Behalf Of s9hill5> Sent: Tuesday, July 17, 2012 1:52 PM> To: mailto:%40yahoogroups.com> Subject: Medicaid HMO( Amerigroup, Americhoice....)> refuse to pay> > > > > > I have a few pts. They have medicare and Medicaid

HMO. Medicare paid most of> the claim ( 99214, $92.64). THere are deductible or coinsurance(99214> $23.16). I sent claims and copies of Medicare EOB to Medicaid HMO. But> Medicaid HMO refused to pay. They stated that they suppose to pay $34.45,> Medicare already paid $92.64, more than Medicaid HMO suppose to pay, so> Medicaid HMO will not pay.> > I was told Medicaid HMO suppose to pay the deductible and coinsurance. > I will appeal. But looks like hopeless. Anybody has this kind of experience?> THanks>

[Guest guest]

Nothing you can do.  However, I am shocked they offer FFS as I have a small panel and have never been offered FFS.  But I actually do OK with the capitation.  Because even my Medicare/Medicaid patients, I at least get some capitation and if they were FFS I would get nothing. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of Art HeinrichSent: Wednesday, July 18, 2012 7:56 AMTo: Subject: Re: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay Just to chime in....In NJ all Medicaid patients were turfed into one of the four Medicaid HMO's as of 2011. If your INS patient panel is low (less that 100 patients) you are paid FFS, not Capitated. Have similar situation with United Healthcare Communuty Plan (formerly Americhoice) that doesn't want to pick up the tab for 2012 Medicare deductible ($140) beyond their basic office fee of $40-$50. Suggestions? To: Sent: Tuesday, July 17, 2012 2:20 PMSubject: RE: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay If you are a primary care physician, in NJ, Medicaid HMO is all capitation, no FFS. You must not be a primary care doctor? Or you are not the patients PCP and then you get nothing. I have never seen a patient with more than one Medicaid plan. Not possible. It’s either Amerigroup, Americhoice or Horizon NJ Healthcare. I don’t know why you would waste time billing plans the patient is not in. Don’t you have their card? Or you can check with the phone in line which plan they are on. If you are not their primary, you need a referral. But in NJ, Medicaid does not balance pay what Medicare does not cover unless it’s the deductible and Medicare has paid nothing. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of s9hill5Sent: Tuesday, July 17, 2012 2:14 PMTo: Subject: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay I am in NJ. These patients, Medicaid HMO do not pay me capitation. Americhoice paid 1 pt 1 visit coinsurance $23. Now I try to bill other Medicaid HMO. But Amerigroup denied.Thanks for your input.>> In NJ, if Medicare pays more than Medicaid allowable amount it is considered> paid in full. Medicaid does not pay the balance like a normal secondary> would. However, if it is an HMO, you are receiving capitation which is> usually pretty fair and you can't bill anyway.> > > > Kathy Saradarian, MD> > NJ> > > > Our squirrels do not behave but are needed.> > > > From: mailto:%40yahoogroups.com> [mailto:mailto:%40yahoogroups.com] On Behalf Of s9hill5> Sent: Tuesday, July 17, 2012 1:52 PM> To: mailto:%40yahoogroups.com> Subject: Medicaid HMO( Amerigroup, Americhoice....)> refuse to pay> > > > > > I have a few pts. They have medicare and Medicaid HMO. Medicare paid most of> the claim ( 99214, $92.64). THere are deductible or coinsurance(99214> $23.16). I sent claims and copies of Medicare EOB to Medicaid HMO. But> Medicaid HMO refused to pay. They stated that they suppose to pay $34.45,> Medicare already paid $92.64, more than Medicaid HMO suppose to pay, so> Medicaid HMO will not pay.> > I was told Medicaid HMO suppose to pay the deductible and coinsurance. > I will appeal. But looks like hopeless. Anybody has this kind of experience?> THanks>