Billing Medicaid for Medicare Co-insurance & Deductible

July 6, 2015
Rick Gawenda

I often receive questions from providers of outpatient therapy services who see Medicare beneficiaries that have Medicaid as their secondary wondering if they can bill the patient for the 20% that Medicare does not pay since either they, the provider, don’t participate with Medicaid or Medicaid is not paying the 20% of the Medicare allowed amount. The simple answer is

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  1. What if the primary is a commerical insurance company? Can we collect a co-pay even though the patient has medicaid as a secondary?

  2. In private practice, in most cases, should therapy claims get paid on Medicaid secondary crossover claims (Medicare is primary) if the therapist each have their own Medicaid # & it appears their category of service with Medicaid is accurate? Thanks!

    1. This is not a question I can answer is because the Medicaid program is state specific and they all have their own rules and regulations.

  3. What if the primary insurance is a United Healthcare Medicare Advantage Plan (HMO)? Our clinic does not participate with Medicaid, and our contract with Medicare states that we must accept assignment and not bill the patient for a Medicare/Medicaid scenario. Am I correct in my assumption that the HMO is technically a commercial UHC plan, so the Medicare contract does not apply, and the patient is liable for the copayment?