The medical coder and biller must know the specific coverage requirements for the various Medicare and Medicaid plans, which must follow federal guidelines. But each policy can have other specified requirements, as well. These requirements are similar to those of most HMO plans, restricting patients to contracted providers, for example, or requiring prior authorization for treatment beyond the primary care provider services.
Although both Medicare and Medicaid fall under the jurisdiction of the U.S. Department of Health & Human Services, there is no national Medicaid program. Instead, each state voluntarily sponsors its own program, often through commercial carriers.
Medicaid must work within the guidelines (such as meeting eligibility requirements for members), but beyond that, each state can do its own thing. Medicare, on the other hand, is a national program, and it must be administered as dictated by CMS.
You absolutely must know the specific coverage requirements for the plans that sponsor your patients. Prior to any patient encounter, look on each patient’s insurance card for the provider inquiry phone number to call to verify benefits and payer specific policies.
Check the insurance card or payer website
Most of these plans assign responsibility for denied services to the provider. Patients who qualify for Medicaid assistance (the insurance program designed for the poor), for example, are unlikely to personally have the resources to pay out of pocket for denied medical services.
Even if the payer denies coverage and indicates that the patient is responsible for the charges, the provider still isn’t going to get paid if the
patient doesn’t have the money.
Medicaid policies that are sponsored by private payers are sometimes difficult to locate. Because each state is responsible for Medicaid program administration and the states often rely on commercial carriers to facilitate these programs, you need to be familiar with these payer guidelines. Ideally, the payer is one that maintains a website that lets providers and the coders view the payer policies.
Look in the plan’s provider contract
In some cases, commercial payers who underwrite Medicaid plans include these plans with their other commercial products in the provider contracts. Having this info in the contract can be beneficial to providers, but you need to make sure that the payer intended for all products to be included. Most payer contracts, however, clearly identify which products are included; any product not listed is excluded.
Make sure you don’t assume, just because your provider has a contract with Payer ABC, that Payer ABC’s Medicaid plan has the same requirements as its standard plan. Don’t assume, for example that the provider can see Medicaid patients without the required referral or prior authorization. Similarly, don’t assume that, just because a referral or authorization was not necessary six months ago, it’s not needed next week.
When verifying coverage for Medicaid patients, make sure you verify all possible scenarios that may occur in the course of the patient’s treatment plan. If a particular procedure is a possibility, call the carrier, give the representative the corresponding code to make sure that that service is covered, and secure any necessary authorization.