Can I bill my Medi-Medi (patients who have Medicare as their primary insurance and Medi-Cal as secondary) patient for the 20 percent copay after Medicare pays?
Generally speaking, the answer is no. A physician who bills the Medicare program for services provided to a patient also eligible for benefits under the Medicaid program must do so on an assignment basis. Additionally, Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997, prohibits Medicare providers from "balance billing" Medicare beneficiaries who have secondary coverage under a state Medicaid plan.
If a physician knowingly and willfully violates the law, he or she faces the possibility of exclusion for five years from all programs that receive federal funding. This means physicians could lose their ability see patients covered under Medicare, Tricare, Medi-Cal, Medicare Advantage (managed care) programs and Federal Workers’ Compensation. In addition to exclusion, the federal government may impose civil monetary penalties.
Physicians who are not currently enrolled in the Medi-Cal program may enroll as Medi-Medi-only providers. More information about Medi-Cal provider enrollment and applications can be found at www.medi-cal.ca.gov.
For more information on billing Medi-Cal and Medi-Cal managed care patients, sign in to the member-only resource section and download the “Side Agreements with Medi-Cal Patients.pdf.”
Ask the SFMS
SFMS will be launching "Ask the SFMS" series on sfms.org and in the San Francisco Medicine journal in the coming months.
We have gathered experts in the field of practice management, payor reimbursement, coding/billing, contract review, legal/malpractice, financial planning/management, health policy, and more to answer questions our members may have.
Click here to submit a question to Ask the SFMS.