6 Basic Points for Medicaid Billing in Any State

medicaid billing

Medicaid billing is more complex than billing Medicare. That’s because the guidelines for Medicaid billing depend on the state, so the claim submission formalities also vary across states.

Medicaid is basically for those in the low-income bracket, the elderly (people over 60), pregnant women, children, and with exceptions for non-elderly (people with disabilities or advanced HIV). Medicaid covers 1 in 5 Americans across a diverse demographic. It also supplements Medicare payments for millions of Americans. Seniors and people with disabilities account for almost two-thirds of Medicaid spending.

Medicaid reimbursement rates are often lower than Medicare and other insurance payers, but at the same time, the claim denials can be higher because of the complex guidelines. The medical practice must check the state’s Medicaid billing guidelines before they submit claims or bill the patient. 

Being aware of the following Medicaid billing guidelines will help you to improve Medicaid collections in your medical office or group practice. Here are six ‘Do’s and Don’ts for Medicaid billing.’

  1. Check coverage: Use the state’s Medicaid website or contact the local Medicaid office to verify the patient’s coverage under the program. Once again, the Medicaid coverage would vary depending on your state.
  2. Billing non-covered services: Only those procedures not listed on the provider’s Medicaid fee schedule (procedure code table) fall under non-covered services. Obtain an Advance Beneficiary Notice (ABN) for submitting claims for medical procedures or services that you suspect may not be covered under Medicaid. The ABN must be obtained before you render the service.
  3. Treat Medicaid billing as the last option: Treat Medicaid coverage as a last resort. If a recipient has other insurance coverage through a third-party source, such as Medicare, TRICARE, insurance plans, AARP plans, or automobile coverage, bill the primary insurer prior to billing Medicaid.
  4. Claiming balance payments from Medicare:  If the patient has third-party insurance, but the coverage provided is lower than the Medicaid fee, you can bill the difference between the Medicaid fee and the third-party payment (minus any Medicaid copayment or coinsurance) depending on the type of Medicaid plan the patient has. Some plans allow you to bill patients, while others strictly don’t. 
  5. Quote the ten-digit Medicaid ID number on each claim: The eight-digit number on the front of the Medicaid identification card is the card control number used to access the recipient’s file and verify eligibility. It is not the same as the recipient’s ten-digit Medicaid identification number, which must be entered on claims for billing. 
  6. Billing NO-show fees: Providers strictly can’t bill Medicaid patients for NO-show fees; check state rules and guidelines before billing. 

Note – Please don’t mention the Social Security Number (SSN)-based Health Insurance Claim Numbers (HICN).

Patients with Medicaid often require more time and resources than the average patient walking into a doctor’s office. As a result, some medical practices may choose to turn away patients with Medicaid coverage. While doing so is a disservice to the profession and in contradiction to the modern Hippocratic oath, medical practices have the right to do so. Make sure you comply with the rules if you are going to refuse service to Medicaid members.

The above guidelines on Medicaid billing are based on Florida Agency for Healthcare Administration. For an in-depth understanding of Medicaid Billing and guidelines applicable in your state, don’t hesitate to get in touch with us. We’d be happy to answer your questions.    

Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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