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

[Guest guest]

In maine  they pay it:)for now.....And our  squirrels behave.

 

This is state dependent.  In CA, it is this way.  If Medicaid says that the allowable service is worth, for example $35, but Medicare already paid you $75, then they consider it to be paid in full.  One of the many reasons we stopped seeing Medicaid patients.

 

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

-- Pratt

--      MD          ph    fax

[Guest guest]

Our squirrels don't behave because they don't have to brave a real winter!!

 

In maine  they pay it:)for now.....And our  squirrels behave.

 

This is state dependent.  In CA, it is this way.  If Medicaid says that the allowable service is worth, for example $35, but Medicare already paid you $75, then they consider it to be paid in full.  One of the many reasons we stopped seeing Medicaid patients.

 

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

-- Pratt

--      MD          ph    fax

-- Pratt

[Guest guest]

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, MDNJ Our squirrels do not behave but are needed. From: [mailto: ] On Behalf Of s9hill5Sent: Tuesday, July 17, 2012 1:52 PMTo: 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]

Reminder: not all HMO providers are paid under a capitation arrangement!  I don't know why everyone thinks this, except for it is the " norm " for their area.  Around here, HMO's are primarily FFS.

Pratt

 

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 PMTo: 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

-- Pratt

[Guest guest]

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]

THese pts have Medicare as primary insurance, Medicaid HMO as secondary.

I try to get the deductible and coinsurance paid from Medicaid HMO.

Thanks,

>

> > **

> >

> >

> > 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

> >

> >

> >

>

>

>

> --

> * Pratt*

>

[Guest guest]

Sorry, in NJ, all Medicaid HMO are capitated. No choice. From: [mailto: ] On Behalf Of PrattSent: Tuesday, July 17, 2012 2:12 PMTo: Subject: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay Reminder: not all HMO providers are paid under a capitation arrangement! I don't know why everyone thinks this, except for it is the " norm " for their area. Around here, HMO's are primarily FFS. Pratt 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, MDNJ Our squirrels do not behave but are needed. From: [mailto: ] On Behalf Of s9hill5Sent: Tuesday, July 17, 2012 1:52 PMTo: 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 -- Pratt

[Guest guest]

I am a primary care physician in NJ. I am their PCP. Americhoice, Amerigroup,

Horizon NJ health all fee for service. No capitation.

No pt has 2 Medicaid HMO. I billed Medicare, then billed Medicaid HMO.

THanks

> >

> > 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]

In New York State I am allowed to have patient sign a statement BEFORE their first vist saying they know I don't take straight Medicaid and will pay their own deductible. I don't have any that are Medicare/managed care Medicaid. Not sure it's allowed here. Maybe someone in NJ knows if this is allowed? These sound like established patients. To: " " < > Sent: Wednesday, July 18, 2012 7:56 AM 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, 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]

You can drop out of Medicaid.  But you can’t participate.  If you participate, then you must accept what they pay. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of MyriaSent: Wednesday, July 18, 2012 8:14 AMTo: Subject: Re: Re: Medicaid HMO( Amerigroup, Americhoice....) refuse to pay In New York State I am allowed to have patient sign a statement BEFORE their first vist saying they know I don't take straight Medicaid and will pay their own deductible. I don't have any that are Medicare/managed care Medicaid. Not sure it's allowed here. Maybe someone in NJ knows if this is allowed? These sound like established patients. To: " " < > Sent: Wednesday, July 18, 2012 7:56 AMSubject: 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>