Medicaid Fee Schedule: Case Study

On this date worker received a call from Ms. Kimbrell, Medicaid Caseworker. Ms. Kimbrell stated Mr. Duncan's nephew who is living at the residence in Curry would need to fill out a Statement from Dependent Relative/Community Spouse form. Because he is living in a home, Mr. Duncan is part owner. She also stated Mr. Duncan would be denied institutional Medicaid because he was not transferred to a long-term facility. However, he could receive hospital Medicaid because he was in the hospital longer than 30 days. The transfer penalty does not apply to hospital Medicaid but if Mr. Duncan ever applies for institutional Medicaid, they would need the person who purchased the home from Mr. Duncan to provide something showing the amount of money he spent

1. A patient that complains about blood is his stool could use the CLIA waved test called Immunochemical Fecal Occult Blood Test. For the non-Medicare/Medicaid payers the test would be an 82272 CPT code and for the Medicare/Medicaid payers the test would be a Go434QW. Both of those test help detect why there is hidden blood in the stool.

Medicaid will paid for the remaining balance that the primary insurance don't cover if that balance is part of the charge fee. Usually patient paid at front for they copay if they want to paid us and we go to submit the claim to the patient 2ndry insurance with copy of the primary payment EOB and Medicaid will paid us the rest of the balance of the patient charge fee visit without passing over the Medicaid encounter rate fee. Sometimes Medicaid paid in full and we have to refund to the patient the copayment that the patient paid from the primary payer but this is hard to know because is depending of the patient coverage with the primary insurance.

When this provider bill with rev codes, they are receiving a payment but then they bill out-patient services they’re receiving a denial G18. Do you know how this provider is set-up to bill?

The A single-payer national health program (NHP) has similarity to the Affordable Healthcare Act. However, it better because is addresses some of the issues that were left out of the ACA. Like, free choice of providers and the preservation of doctor–patient relationships are threatened by our current system (Gaffney, Woolhandler, Angell, & Himmeslstein, 2016). With each enrollment cycle, patients seeking affordable premiums or changing jobs must often switch insurers and risk breaking existing relationships with providers.

Medicaid Administrative Costs - It is possible to obtain reimbursement for administrative activities directly related to Medicaid for either obtaining Medicaid coverage or assisting beneficiaries in obtaining care. To begin the process, there will need to be a discussion with the state Medicaid office and completion of several pieces of documentation before billing for costs can occur. It will require a written plan and documentation of time spent on the administrative activities. The two specific types of reimbursement are Medicaid Administrative Claiming (MAC) and Targeted Case Management (TCM).

Following the death of a Medicaid recipient, the program not only can but must attempt to recover costs from the estate of the deceased. Medicaid's official site says:

The Affordable Care Act (ACA) has been the biggest milestone to date in American health care policy (Saldin, 2011). There is nothing more complex or controversial in recent history than the passing of the ACA in 2010 (Davidson, 2016). The United States Supreme Court ratified the constitutionality of the Patient Protection and Affordable Care Act on June 28, 2012. With this, there were certainly challenges facing the full implementation of the provisions of this act by 2014.

With the implementation of the ACA, many states have expanded their Medicaid programs to include a larger population of low income individuals and families that were not able to obtain health insurance prior to the law. Some of the issues that state legislators struggle with are the overall cost of providing services for the additional recipients, staying within budget, determining an adequate approach of offering quality care, and providing adequate coverage for each recipient. Even though the cost of Medicaid expansion within each state has increased the budget for the program, new appraisals has shown that Medicaid programs spend less per enrollee than commercial health insurance and much of the increase in Medicaid expenses originate from the increase in enrollment in the programs (Coughlin, Long, Clemens-Cope, & Resnick, 2013).

After viewing this providers claims, I notice that the provider is billing on a CMS1500 and UB-04 for Home Health Aide Services. Because Home Health Aide is normally billing on a CMS1500, the claims are denying for G04 –Inappropriate billing for the contract. However, provider is also billing on a CMS-1500 which is passing the G04 denial to deny for OHI. I called Emery McDonald at 2:32pm to go over the details of his claims, however, he’s receptionist advise he out today and I left a voice mail advising I would call him back. I will call again tomorrow.

People don’t like being sick, however, some Missourians forego preventive care, required doctor visits and beneficial medicines because they cannot afford them. They may be working in part time jobs, seasonal jobs or other unskilled labor jobs and lack affordable health insurance. They are the poor people below the 138% federal poverty level (FDP). According to Chris Kelly, a former Representative of the Missouri House for district 24, the West Plains hospital Ozark Medical Center’s (OMC) service area includes more than 9,000 uninsured adults (p1). So, what do you do when you are poor and sick and can’t afford a doctor’s visit? You go to the emergency room of a local hospital and the hospital absorbs that

Providing grants to health care facilities with Medicaid patients will enable these sites to conform with the goal. So your proposed idea of providing grants to small offices and rural hospitals needs to be considered. My cousin (he is a vascular doctor) opened an office in Florida and had to close it because payment issues with patients receiving Medicaid. As you can tell, Medicaid has limited budget therefore will affect those receiving Medicaid benefits.

Affordable care act is a law that was passed in March of 2010 to help decrease health care cost and make it more affordable for all Americans. The affordable care act is set to decrease the number of uninsured Americans, qualify more for Medicare and Medicaid, increase the quality of care, promote prevention, extending funding for the children, and help with funding in the communities. The goal for affordable care act is to have everyone insured, no matter what income class you are in. The affordable care act is there to insure everyone so that prevention will increase. It will increase by being able to get check ups and children being able to receive vaccination. If you are not able to qualify for Medicare or Medicaid there

Medicaid initially established that each state is responsible for designing their medical costs to pay medical care for the poor. Also, Medicaid created as a voluntary program for each state; they have to have the choice to participate. For one thing, because of the rising costs of healthcare, it has been difficult to bring Medicaid recipients into the “mainstream” of United States (U.S.) medical care. Donald R. Barr notes, “between 1975 and 1989, the cost of the Medicaid program increased by an average of 11.9 percent per year before adjusting for inflation” (172). The rising costs of healthcare are necessary for each state to determine if it is beneficial for them to participate in the Medicaid program. As the government level of payment is determined by each state economic condition. For instance, a state with lower per capita income will receive more government funding. A state with higher per capita income receives less reimbursement for program costs. Therefore, on December 31, 2010, many states continued to experience budget cuts. As a result on August 2010, Congress increased reimbursement rates through June 2011.

In my hometown state of Colorado, one of the piloting states who are implementing a new method of delivering and paying for Medicaid beneficiaries’ care to coordinate a broad range of health and social serves by shifting some of the financial risk for the costs and quality of care to providers. Colorado’s Accountable Care Collaborative Program is providing Medicaid beneficiaries care through an accountable care organization (ACO) delivery model. Medicaid contracts with one regional care collaborative organization (RCCO) that works with providers that are part of the Primary Care Medical Providers (PCMP). “Medicaid oversees that the regions get the medical management, admin support, while they seek to ensure care coordination to the Medicaid enrollees and integrate smoothly with the care in hospitals, with social services and specialist” (Ellis, Gifford, & Smith, 2014). Many of the ACA’s provisions affecting Medicaid eligibility and enrollment went into effect during 2014, most significantly the Medicaid expansion implemented as an option for states. All states were required to streamline Medicaid enrollment and renewal processes, transition to a uniform income eligibility standard and coordinate with the new marketplaces (Ellis, Gifford, & Smith, 2014). Colorado has also set out to integrate behavioral and clinical health care through incentives to providers. Colorado’s first annual report indicated progress and success for what the ACO set out to