Forum - Questions & Answers

Apr 21st, 2015 - ARlamb1972 1 

Out of State Medicaid

We have an issue with a United Health Care Medicaid plan out of Tennessee. We are in NY and treated a patient in the ER. The patient came into the office for a follow up a couple of days later. We are out of network with this Medicaid due to it being out of state. Now our doc was paid for the ER consult, but the office follow up and surgery have been denied for being out of network and UHC states it is not patient responsibility. We had made the patient aware of the fact us not participating with plan when he came in for the follow up from ER. He stated he would be self pay, but in the meantime tried to obtain an out of network referral to cover. The referral was in limbo with UHC, and due to the severity of his condition we continued to see patient and did surgery. The out of network referral was denied therefore all our claims were denied by UHC. We then looked to the patient to take care of the unpaid balance which he did not pay. Now UHC is stating we can not bill the patient that we must write off the balance as we can not bill a Tennesse Medicaid patient for an approved service. The services were not approved, and the patient did sign our financial policy which states that if a referral is not in place at the time of service they may be rescheduled or asked to pay cash. The patient wanted to be self pay and signed the form. Are we correct in trying to collect the balance from the patient? We feel we did everything we were suppose to do, and made him aware. Any input would be great.

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Apr 21st, 2015 - LBAROGIANIS 250 

re: Out of State Medicaid

Hello.. Love UHC.. well the same thing happen to us. I had to sign us up and submitted the paper claims with enrollment and they back dated us. So we ended up getting paid but it did take a couple of months. I would think that you could bill patient regardless, however, in Florida there is a law for HMO"s and if you accepting seeing the patient in the office setting, then basically you accept their plan and their fee schedule. Good luck anyways!

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