Having Medicaid coverage provides important protections when it comes to paying for healthcare services. Medicaid providers are limited in what they can charge Medicaid enrollees for covered services. But there may be times when Medicaid does not pay a bill as expected, leaving an enrollee wondering what to do next. This article provides an overview of Medicaid billing rules, reasons Medicaid may not pay a bill, and steps enrollees can take if faced with an unpaid medical bill.
Medicaid Billing Rules
Medicaid has strict billing rules in place to protect enrollees from being overcharged, Some key protections include
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Balance billing prohibited: Medicaid providers cannot “balance bill” by charging enrollees more than the Medicaid reimbursement amount for covered services. The only exceptions are if the enrollee agreed in writing in advance to pay extra for non-covered services.
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Collecting cost-sharing limited: Medicaid enrollees with incomes up to 150% of poverty have no cost-sharing. Other enrollees have limited cost-sharing that providers can collect.
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Charging for missed appointments restricted: Providers cannot charge Medicaid patients for missed appointments. They can only bill if the patient agrees to pay in writing in advance.
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Retroactive billing not allowed Providers cannot bill enrollees for services delivered before they enrolled in Medicaid Medicaid rules require providers to bill the program directly in these cases
Reasons Medicaid May Not Pay a Bill
Even though Medicaid recipients are protected from getting bills, there are times when they may get one for a service that was covered:
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Claim rejection: A provider’s claim to Medicaid for payment may be rejected due to a technical error, expired authorization, late filing, etc. This delays payment until the issue is fixed.
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Coordination of benefits If the enrollee has other insurance Medicaid may not pay until after the primary insurance. Errors in coordination can result in denied claims.
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Provider not enrolled: Medicaid will only pay enrolled providers. If the provider is not enrolled, the claim will be denied.
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Limits on services: Physical therapy, home health care, and other services are limited by Medicaid. Claims may be denied if a limit is exceeded.
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Eligibility issues: Gaps in Medicaid eligibility or errors in processed applications/renewals can prevent claims from paying.
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Program integrity: In some cases, Medicaid may suspect fraud and withhold payment while investigating, leaving claims unpaid.
What to Do About Unpaid Medicaid Bills
If you receive a bill for a service that Medicaid should have covered, take the following steps:
Talk to your provider
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Ask why Medicaid didn’t pay and if they can resubmit the claim or file an appeal.
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Ensure they have your correct Medicaid ID number and other information needed to bill properly.
Contact your Medicaid plan
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Call member services and ask them to look into the rejected claim.
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Have your Medicaid ID number, date of service, provider details, and claim information ready.
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Ask them to coordinate benefits if you have other insurance that should pay first.
Submit complaints
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File complaints with your state Medicaid agency and managed care regulator if billing rules were violated.
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Report suspected fraud if that may be an issue.
Request case management
- If facing extensive unpaid bills, ask for a case manager to provide personal assistance disputing claims.
Seek legal assistance
- Nonprofit legal aid organizations may be able to provide advice or representation if attempts to resolve unpaid bills fail.
Explore financial assistance
- Ask providers if they offer financial assistance or payment plans for patients struggling with medical bills.
Billing Dispute Options
There are formal options to dispute medical bills through Medicaid and your state insurance department:
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Medicaid fair hearings: Enrollees have a right to fair hearings to appeal Medicaid denials like unpaid claims.
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Managed care appeals: Those in Medicaid managed care can appeal denied claims through their health plan’s appeal process.
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State complaint processes: Every state has a process to submit complaints about health coverage, including billing issues.
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Insurance department: Unpaid claims or improper bills can be reported to state insurance regulators for investigation.
Key Takeaways
Having Medicaid provides important billing protections for enrollees. But errors can still occur, resulting in services not being paid for as expected. By understanding billing rules, tracking down the reason for non-payment, and utilizing complaint processes, enrollees have resources to resolve unpaid Medicaid bills. Reaching out promptly is important, before unpaid bills are sent to collections. Healthcare consumer assistance programs are available in many states to help navigate billing disputes.
What if I still owe the bill?
If you still owe the bill or a part of it, here are some options:
- Negotiate the bill down to an amount that you can afford
- Ask if the provider will accept an interest-free repayment plan
- Look for help paying medical bills, prescription drugs, and other expenses. Some nonprofit organizations provide financial help as well as help for drugs necessary for your medical care or even certain medical conditions.
- Be careful about using a credit card or a medical credit card to pay off the bill. There may be high interest and you may lose the ability to negotiate the debt. There may be better options like an interest-free repayment plan.
You also have protections from faulty credit reporting or if you are contacted by a debt collector.
Do you owe the bill?
First, make sure that you owe the bill. You could have already paid it. It’s also possible that the provider or debt collector has confused you with someone else with a similar name.
Second, check the charges. If something doesn’t look right, ask for an itemized list of charges. Some questions to consider:
- Are the charges accurate?
- Do they reflect the services you received?
- If you have insurance, do the bills reflect the payment by your insurance and reflect what the provider understood would be covered?
- Do any of the charges indicate a service was “out-of-network” when it wasn’t?
Look for billing errors like being charged for the same service or treatment twice. If you are unsure, talk to the accounting or billing office of your provider. Their number and contact information will be on the billing statement. You want to do this quickly so you can get any charges resolved and to avoid late fees and interest.
Third, if you disagree with the charges or want more information, you have the right to an appeal with your health insurance company . You have a right to both an “internal appeal” and an “external review” of the charges. Check your health insurance policy documents and the “explanation of benefits.”
Finally, remember that you can also dispute a medical bill with a debt collector or a credit reporting company.
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FAQ
How to submit unpaid medical bills to Medicaid NY?
What is the time limit for medical billing in Missouri?
Can Texas Medicaid patients be billed?
How do I submit unpaid medical bills to Medicaid Florida?
What if I am being balanced bill by a Medicaid provider?
If you are being balanced bill by a Medicaid provider, please contact CHA at 888-614-5400 for help. If you have Medicare and are a Qualified Medicare Beneficiary (QMB) you are protected by federal law from balance billing by a Medicare-enrolled provider for amounts above what Medicare paid.
What happens if Medicaid doesn’t cover a service?
That’s because a healthcare provider is required to tell you when Medicaid doesn’t cover a service and confirm that you agree to pay the charges — before providing a service. When a patient receives a bill for a service they thought was covered, “the majority of the time we get those charges removed from the bill,” Palmer said.
Does Medicaid pay for other drugs and services that medicare doesn’t cover?
Medicaid may pay for other drugs and services that Medicare doesn’t cover. Contact your State Medical Assistance (Medicaid) office. People who have both Medicare and full Medicaid coverage are “dually eligible.” Medicare pays first when you’re a dual eligible and you get Medicare-covered services.
Can a Medicaid provider charge me more than Medicaid paid?
This means that the provider cannot charge you more than what Medicaid paid, unless you make a private written agreement to pay more or you were told that Medicaid does not cover the service you need and you agreed to pay out of pocket for it. If you are being balanced bill by a Medicaid provider, please contact CHA at 888-614-5400 for help.