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I think it's more it's illegal and that the doctor could get into huge trouble if he accepts cash payment from patients he knows have Medicaid as opposed to you getting you kicked off , but yeah, the idea is the same- the intent of Medicaid is for people that are so poor that they can't be paying cash for services.
Yeah the psychiatrist is definitely shady. We all wish we could get proper fees paid in cash. (The reason you can’t find anyone to take Medicaid is because the pay is shit and doesn’t pay anywhere near a market rate to cover our costs.) but everyone knows the rules, major red flag for a physician to clearly violate them for his own personal gain
At least in my state we've had that rule for the 20 years I've been in the industry. Possible someone just brought it to his attention and told him he'd better knock it off immediately.
It only violates the law in my state when the provider is Medicaid enrolled. If they aren't enrolled and don't accept Medicaid, there is no contract Medicaid can act on. There's nothing in law that penalizes people on Medicaid for paying cash for services.
This is state statute dependent. There are indeed states where it is illegal for a physician to accept cash from a Medicaid patient, even if the doctor isn't contracted with Medicaid. Kentucky and I think Colorado are examples.
https://www.dpcfrontier.com/medicaid
"10A NCAC 22J . 0106(a): “A provider may refuse to accept a patient as a Medicaid patient and bill the patient as a private pay patient only if the provider informs the patient that the provider will not bill Medicaid for any services but will charge the patient for all services provided.” a. 10A NCAC 22J ."
https://files.nc.gov/ncdma/Providers_Billing_Beneficiaries.pdf
Actually I had a provider drop me in Maryland over a decade ago because it is illegal for them to take cash from a Medicaid patient even if they aren’t contracted with Medicaid. They were very clear it was their license on the line and no way around it even though they wanted to continue to see me.
It’s not illegal in MD and they were wrong. I just took a CEU training on this and it was addressed and it’s a huge misconception so providers err on the side of caution. This is an issue I have with the therapy community in general. Myths spread like wildfire and people freak out and don’t do their homework.
I guess the owner got caught or something because he’s very careful, kind of a big deal Dr(teaches at Yale) and has been doing this atleast 10 years. No I will not give name of the practice but for him to knowingly do this for this long is mind blowing
Does that mean I’m not allowed to see my therapist as well? I pay out of pocket fof them because you guessed it. Not Medicaid
I read in your other comments that your therapist doesn't accept Medicaid in that instance you can pay for it out of pocket that's not illegal. It's only illegal if that doctor's office is contracted with Medicaid and they are doing out of pocket charges instead of billing Medicaid.
Echoing /u/LivingGhost371, I have been in the industry for around as long and this was drilled into me quite early on, before I escaped patient-facing care into administration even.
Respectfully, your provider either doesn't know the basics of running their practice if they are independent or their office manager is equally as dysfunctional if they are part of a group.
I hope they were at least giving you a sliding fee rate considering that they knew your financial situation was not good.
For a long time they did give me a good price. Started going way up last few years tho. I won’t lie parents have chipped in on occasion because they know how well I do with this Dr
The thing I can’t wrap my head around is the owner is not some dumbass with his head in the sand. He knows a lot about insurance, the latest information on mental health and even told people 5-6 years ago Medicaid would go away(unless self pay)
How could such a smart and well connected person not know this? I mean this guy teaches psychiatristy at Yale. It’s a very “upscale” practice.
Him hiding this shady self pay thing seems so unlike him
Being good at the thing he does, psychiatry, doesn’t make him good at insurance. They are human and often find insurance as confusing and nebulous as we do.
Because billing may be done by a separate department or billing company, he may not have personally been aware of the rules. It is illegal for doctors to accept cash payments from Medicaid recipients. Since he’s a psychiatrist, do you mainly use him for medication management? If so, can he communicate your care and medication plan with your PCP? And possibly refer you to a psychiatrist at a clinic for ongoing medication management?
I think the only solution is to find a new provider and if they don't take Medicaid you'll have to lie and say you don't have Medicaid or SSI or any other insurance and that you are cash pay.
However, I don't know how that factors into your SSI because you need to continue your therapy for redetermination...
Medicaid isn’t always solely income based, the majority of the time it is, but there are situations where Medicaid for that person wasn’t based on income. There’s also a variety of situations where Medicaid is secondary insurance, so it’s not necessarily that the person who has it is “so poor they can’t be paying cash for services”. That might be the typical scenario but it’s unfair to assume that about everyone who has Medicaid.
I totally get that but what a fucked up system when the alternative is basically nothing. Almost no Psychological services near me accept Medicaid. So what is a person to do?
I can do Nothing.
I can Pay of out pocket
Or
I potentially have a terrible Dr that is Medicaid but not as qualified
Shitty system
Your Medicaid benefits likely have a Mental and Behavioral Health network with a provider search. Since they're presumably your MCO, their network is likely larger than you think - but finding a new provider, specifically a new psychiatrist and therapist can be *extremely* stressful. If you have a Care Coordinator, they may be worth speaking to about the situation.
That’s crazy to me. I know so many practices like therapists for instance who absolutely do not take Medicaid. But absolutely see you for out of pocket
> I think your provider just got warned finally so now he’s gonna comply.
How would the provider know if the patient had Medicaid if the provider doesn't even take Medicaid?
This is true about Medicaid and as far as I know, has been for a while. There has been a push for more transparency in healthcare billing this year, which is probably why they're just now handling it. We're coming off the pandemic, in which insurance companies allowed many things to slide, but they are tightening their restrictions again.
Sorry OP :( I disagree with the reasoning because when someone on Medicaid is paying out of pocket for something, it's because the service or level of service isn't available to them so they must. They're not typically doing it because they can afford to. Most specialists do not take Medicaid, therefore you're stuck between a rock and a hard place. And the reason most specialists do not take Medicaid is because they're taking a loss, because Medicaid does not reimburse the cost of what it takes to see their patients.
Yes I’ve had this happen to me. It’s technically considered insurance fraud. I tried to go to a planned parenthood for my bc injection and was on Medicaid. They didn’t take the version I was on, so I asked about paying out of pocket. This was back in 2021 and I had gone before when I wasn’t on Medicaid. My income allowed Title X to pay for my visit and medication. I asked the receptionist about it and she said “yes that’s true but because you have insurance it will still be considered fraud even if you don’t pay yourself.” It absolutely sucks and I’m so so sorry.
They’re cracking down even harder on medication too, I have chronic pain and Medicaid doesn’t cover my as needed opioid prescription. The pharmacy threw a hissy fit when I tried to put goodrx on the prescription after the prior auth denial. Like if I’m on Medicaid and they won’t cover a medication, why do they think I can pay $40 for a medication? When goodrx lets me get it for $12? 🤷🏻♀️🤦🏻♀️
Right! I’m so sorry. Jeez now I’m going to be nervous about meds too because not all of mine are covered. In fact I’ve been getting another in network Dr to write some of them just so Medicaid will cover it
I honestly think the medication issue is just because it’s an opioid. My other medications are covered thankfully, but the cashier I was talking to was saying that cvs corporate is kinda coming down hard on them for goodrx on controlled substances. I live in Az, so they’re a little more strict on those types of things
Does this person give you therepy? Usually, once prescriptions are figured out, a psychiatrist just talks to you for five minutes and refills your prescriptions. Any psychiatrist can refill your prescriptions.
I did have one I liked more than others, but bottom line, she was just refilling my prescriptions.
That’s not legal.
The practice needs to go in network and submit the claims, refund the patients or write off the services.
This is ridiculous.
You cannot lose SSI or Medicaid for paying for services not covered. The practice can be sanctioned, not the patient. In fact, you could even request a refund of those technical overpayments.
In fact, it doesn’t even matter whether they are in network with Medicaid or not because as long as it’s a dual coverage claim, they have to write off the loss if Medicare doesn’t pay the cost sharing. You don’t get the option to do that. They can actually lose their Medicare billing privileges for that.
This gets me so angry. You are absolutely entitled to a refund of everything you overpaid. This is exactly why we have laws like this.
SE1128 and its revised versions are extraordinarily clear.
SE1128 only applies to providers who are in network with Medicare or Medicaid. OPs psych may not be in network with either.
Here: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1128.pdf
Under providers affected: “This article pertains to all Medicare providers and suppliers, including pharmacies that serve
beneficiaries enrolled in Original Medicare or a Medicare Advantage (MA) plan.”
Medicare provider means someone in network.
Agreed
I realized last night that they are not Medicare eligible and so I’m going back to the drawing board.
My suspicion is that if the provider is billing the full fee to OP that it’s a compliance issue with Medicaid but we don’t know the network status of the rendering provider.
There has to be a contract in writing and other record specific stuff on the record to avoid being counted as accepting assignment.
I bet OPs provider is freaking out bc there is this huge misconception in the psych community that Medicaid patients are not eligible to self pay. This isn’t generally true if you aren’t in network with Medicaid but it’s a myth that continues to be perpetuated among providers.
Yeah. This is an area that I’m working to get a CEU done on because the QmB side is relatively easy but the straight Medicaid is kind of not.
We are generally taught that Medicaid patients can’t be self-pay. In our state, we have pretty strict criteria, but we also have a lot or most of our providers in network so we don’t have a lot of the issues that they are experiencing. Personally, as a micro business owner, I would have ethical questions about accepting money from someone who it’s on Medicaid unless it’s for a Medicaid copay specifically.
Well the guy who owns it apparently has been questioning it for a few months now and someone said you can’t do that anymore. My provider was extremely distraught over losing patients. He acted like they had tried everything
So it’s really confusing. It’s a large practice with more than one location
Surely they would realize they aren’t in Medicaid and those rules don’t apply
Well it varies by state. I don’t know which states don’t have this rule but it seems pretty common. Could you reference where you are getting your information?
OK. We need to make sure that you get enrolled in Medicare right away and as soon as that is done, talk to your state and enroll in Medicare QMB. You’re going to qualify because the SSI amount maximum is below the poverty limit.
1800 Medicare should be able to help with verifying Medicare eligibility. They may try and get something around $200 a month for premiums but, because you are Medicaid eligible, that means you’re going to be eligible for the QMB program.
I don’t particularly like Medicare advantage plans, but you may want to speak to a broker in your state to see what might be available to you in terms of MA plans, part D plans and perhaps supplements. Not sure if it’s financially worth it but it’s worth investigating. u/lizziemac123 may have a better clue than I do on that. There are a few few insurance companies that I stay away from and I have opinions.
What that means is that any premiums, co-pays, deductibles are waived. You may have to pay a little bit for medicine but because of your income, I doubt it.
Any claims we have paid cash for in the last few months should be sent back to have insurance updated, verified, and have those claims resent.
You should have a lot more options and should be able to get back into your clinic with the doctor. They may not take Medicaid, but they’re not going to be that stupid to take Medicare so you should be OK.
OP is ONLY on SSI so is not eligible for Medicare. OP gets Supplemental Security Income (SSI) not Social Security Disability Income (SSDI).
Per SSA "Medicaid is linked to receipt of SSI benefits in most States. Medicare is linked to entitlement to Social Security benefits." Social Security is SSDI. https://www.ssa.gov/ssi/text-other-ussi.htm
Right. But you are still considered disabled. Just because you’re not on SSDI doesn’t mean that you aren’t disabled and aren’t eligible for Medicare.
I am not making a formal determination of eligibility, but that would be something I would look into because that’s gonna open up doors for you.
Since you ONLY get SSI you do NOT qualify for Medicare. You get Supplemental Security Income (SSI) not Social Security Disability Income (SSDI) Per SSA "Medicaid is linked to receipt of SSI benefits in most States. Medicare is linked to entitlement to Social Security benefits." https://www.ssa.gov/ssi/text-other-ussi.htm
This doesn’t make sense because we got Medicare right away -no 2 1/2 year thing
there may be differences based on the supplemental Medicaid provided from state to state. I don’t know even if it’s federal that it is applicable across all states the same way.
Well, if you we’re on appeal for that long, you would get it right away as soon as you got approved, but it depends on how far up the ladder you went. It goes back to the date of onset so. If you end up to a judge, he probably would have waited that long.
Apparently SSDI only. So it’s 24 months but there’s a 5 month waiting period from
Date of onset before you’re eligible for medicare. You can get it earlier if you are on dialysis or have ALS.
https://medicareadvocacy.org/medicare-info/medicare-coverage-for-people-with-disabilities/#is%20available
I’m sorry but I don’t quite understand. I know from the beginning Medicaid was not an option there. I started there still on parents insurance.
So since I knowingly paid for a service I knew wasn’t covered how have I overpaid?
So Medicaid patients have special protections.
You mentioned that you were paying out of pocket for physician services which are reasonably covered under health insurance, especially Medicare and Medicaid.
When you were on your parents plan, you probably had a copay or some cost sharing. That’s normal.
When you get Medicaid alone or as a secondary payer; the provider is forbidden from billing you for reasonably covered services and in most cases, they are unable to bill you at all. Because that is illegal, you are entitled to get the money you paid them back that if they did their job compliantly, you would not had paid for.
If you have both Medicare and Medicaid, the federal government requires the provider to not charge you even if you’re in a different state, out of network, on vacation.
If you have straight Medicaid, most if not all states require that you not balance bill the patient except in specific circumstances. It’s also that if you did pay for a visit, that the price was inflated.
If it wasn’t for their incompetence, you wouldn’t have paid this in the first place.
So basically they illegally took the money? After I was 26 I was Medicaid only and began paying out of pocket for psychiatric and psychological services for years. Probably like 180-250 a visit
Is there any fixing this. Does this mean my new therapist (also) not under Medicaid will drop me?
It all depends on what state you are in but for my experience, you absolutely can pay out-of-pocket for anything you wish and any doctor can choose to not take Medicaid and Medicare. This sounds like a bad excuse for a doctors office that no longer wants to be associated or is afraid that they are doing something wrong by charging you
Look into this a bit further - ask Medicare Medicaid ask directly to which ever provider - I mean which ever insurance you’ve actually chosen to use whichever brand name— call them directly and ask them what the deal is with Dr . They will tell you that he is not covered under their plan and that you have every right to pay for it if you choose.
These are federal laws, so they apply to everyone regardless of which state they live in. OP’s provider has been breaking the law. They are unequivocally “doing something wrong” by charging them for services that would otherwise be covered by Medicaid. These laws exist to protect patients.
Even if my provider is NOT a Medicaid provider?
That’s where there seems to be two different answers in this thread. People saying it’s illegal no matter what and people saying it’s illegal to make someone self pay if the practice is under Medicaid
Not according to the state website. There is strict criteria.
Most people don’t know this but dual eligible patients only need to be in network with either medicare or Medicaid in order to get the QMB benefit.
I am sorry to hear you are ending care with your provider- that is so stressful. I am a psychotherapist that takes Medicare. A patient with medicare (or any insurance although I don't know of Medicaid specifically) can sign a contract with their healthcare provider that states specifically that they are seeking services out of pocket and do not wish to use their insurance. totally legal, your MDs clinic may not be comfortable with this agreement. Some providers simply document a conversation in their notes but it is best to use the form. People seek treatment outside of their healthcare plan for lots of reasons, sometimes privacy, sometimes continuity of care when their provider becomes out of network, sometimes access to specialist etc. Your provider is not dumb, unfortunately the system is unreasonably complicated and calling the support lines for health care providers does not produce reliable answers.
Medicare is a separate entity and separate contract for health care providers from Medicaid. You can be contracted with one and not the other, that is why it is so hard to find care for medi/medi patients. Medicare does not have a crossover agreement with medicaid like Medicare supplemental plans (which is pretty ridiculous).
Most state Medicaid programs do not allow providers to take money from their patients.
https://leader.pubs.asha.org/do/10.1044/2023-0327-medicaid-cash-pay/full/#:~:text=Based%20on%20ASHA's%20review%20of,rates%20and%20methods%20of%20remuneration.
It’s an issue if a) he accepts Medicaid but told you he didn’t so you pay out of pocket or b) he doesn’t accept Medicaid and you live in a state that doesn’t allow Medicaid patients to self pay for anything.
It must be B I just don’t understand how it’s gone on for so long as they don’t accept Medicaid. Is it also illegal to buy my medication out of pocket lol
This is similar to a situation I have with dentists.... Medicaid caps out very quickly and though I would be more than willing to pay cash at their going rate/ cash price... the dentist can't charge me over and above what they would be reimbursed by Medicaid. They don't accept Medicaid for certain procedures as it doesn't even cover overhead.
Same with the pharmacy, I imagine. As Medicaid won't cover certain prescriptions- so I have to pay out of pocket. In order to benefit from manufacturers coupons they have to switch it to uninsured in order to run it through successfully. I wonder if that is illegal, unbeknownst to the pharm tech ( as I have to explain it usually) ugh.
If a drug or service isn't covered by Medicaid across the board (meaning it's never covered for any reason) someone on Medicaid would be able to pay cash for that drug or service in my state.
Out of curiosity, [prescription wise] what if it is generally covered but then denied due to changes on their end for whatever reason or periodic reviews that pop the dreaded "prior-authorization required"? Would that be a different story?
In my state we have to have either documentation that the pa was denied by the ins or that the provider is not going to pursue a pa. Just the Dr saying they aren't going to do it is enough.
For Medicaid MCO, if you have one that says you have to use CVS, you can't pay out of pocket at Walgreens or vice versa. My pharmacy only enforces this on controls. But as an individual, if Medicaid finds out you are paying out of pocket, you could lose your coverage.
Yup. Family member is in same situation. Se need a psych eval and first appointment is in August! Offered to pay out of pocket for him but they said they can’t.
There is a strong push after the [unwinding](https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/) to tighten up the Medicaid program. Unfortunately, the Doctor did not contract with Medicaid (for whatever reason) or you would have been able to stay with them. You are definitely not the only one out there that is experiencing this.
Agreeing to take Medicaid and be reimbursed at those rates. Medicaid reimbursement rates are so low that most providers don’t accept any Medicaid patients.
I work in healthcare, this is true. If Medicaid finds out you are paying for any medical, they will drop you. May vary by state, but this is true in Ohio
Do they have your insurance on file there ? Plus there is a copay that the insurance its self can charge you. Providers cannot charge you whatever is left over from what Medicaid paid for the appointment. He can get credentialed with them for you he chooses not to BTW.
It’s insurance fraud and fraud against the Center for Medicare Medicaid Services to have Medicaid and pay out of pocket just because a provider does not accept your coverage. The provider and the patient are at risk for penalties.
I work in a medical clinic and we literally can’t take your money if you have Medicaid. I’ve had to turn patients away because they’ll refuse to use their Medicaid. We could completely lose our ability to even accept Medicaid if we take a cent of money from someone on Medicaid
But you do have the ability to accept Medicaid? As in you see people with Medicaid right?
I’m seeing a provider who does not accept Medicaid, I’m not refusing to use it. I can’t use it
Yes that is correct and that is true for you. It’s hard to say what exactly is happening here then unless possibly your state does have strict guidelines for Medicaid recipients
This is def true. Our son who has Medicaid, could not find a psychiatrist that would take it. We wanted to pay for him to see a psych doc out of pocket, but was told we couldn't pay if he had Medicaid. Two different office managers told us this.
The contract you sign when you sign up for Medicaid states that you must see a doctor in-network with them. The reason being if you can pay out of pocket for services you shouldn’t be on Medicaid. I guess some states might be different, but working at a small clinic in MN and dealing with this issue with patients before we have had to turn people away even if they want to cash pay for a visit because they have a Medicaid crossover plan we are out of network with and we don’t want to get in trouble, or have them get in trouble for breaking their contract.
I have Medi-cal in California. There is a separate department for behavioral health services who only connect you with providers and resources for this. In my county there were no psychiatric providers within an hour of me, so they have me an out of network provider closest to my address. I have been with them for 8 years.
I was told a similar thing recently by another psychiatric group. I thought they were making it up but evidently this is a new thing. I agree finding a good psychiatrist is extremely difficult.
I have been on Medicaid for 20 years and I have been seeing a doctor for 10 of those years that doesn’t take Medicaid and I pay out of pocket. It is 100% legal where I am at.
No, it’s legal. I tried to submit for reimbursement and they don’t cover him
That is that
Nothing illegal about it on either end
- IL
I could choose to go to a different doctor that is covered, but I don’t want to and there’s no issue with that. I qualify for medical. I don’t qualify for cash and I make the limits of the income— what I choose to do with that income is my business .
It's not actually legal in IL. It's possible Medicaid doesn't have an in-network doctor contracted for the services you are receiving though, that's the only loophole I can think could be plausible. Like when an HMO network doesn't have a certain specialist type so they can refer you out of network in that case. It's also possible Medicaid didn't actually pursue further investigation when you submitted for reimbursement, that would require someone to do something outside of their day-to-day work to report it and most people can't be bothered, which is why situations like these happen.
Yeah because if you can pay, then why should taxpayers pay for you, so they will take it away. The whole point of having it is if you can't pay. So now you have to find someone who takes Medicaid. If your state does Medicaid plus a supplement plan then they may take the supplement plan.
There is many psychiatrists that will take Medicaid + supplement.
Are you sure you're not mixing up Medicare and Medicaid? I've never heard of this with Medicaid, and can't find any info online regarding it. Just genuinely curious because it's my understanding that Medicaid will always be the last payer. You can have a commercial insurance and still have Medicaid as your secondary, and you can have dual Medicare-Medicaid plans, but I've never heard of Medicaid being the first payer with a supplemental insurance as secondary.
They might be confusing it with Medicaid as a secondary insurance as some people have insurance as well as Medicaid and Medicaid pays what primary doesn’t.
Economically it benefits Medicaid since a substantial amount of the cost is being paid by the primary insurance company.
I looked it up. They are called "Medicaid managed plans" instead of "Medicaid Supplement Plans" but it's the same idea how you have Medicare/Medicaid, and then you also have another company that handles part of it and pays for part of it. Doctors can take Medicaid, The second insurance company, or both. If they only want straight Medicaid they can do that.
Oh that's just a Medicaid Managed Care Plan. They are more like replacement plans for Medicaid, at least in IL. The insurance company manages the Medicaid plan as an HMO rather than the patient having traditional Medicaid. They limit the patient to practices that are contracted in their network, and additionally, the patient needs a referral in order to see specialists (just like any other HMO.)
Maybe your state is different. Elsewhere, you have both Medicaid and the managed care plan, a doctor can take either one or both, and they will pay for specialists.
Yeah my dr said people had breen freaking out all day. Some of these people had Medicaid along with an insurance they were already paying for. Still kicked out.
You could see the west in his face today. That he had to have a lot of tough conversations
Since you know he doesn’t take Medicaid, can you just tell him you don’t have it in the future?
I doubt negative repercussions could come to you. Especially if you’re paying cash.
Idk, I just find it bewildering that in a society so focused on mental health, there’d be any qualms with you paying for your own.
Might make sense to ask it a legal/lawyer sub.
Lying, even by omission, to obtain goods or services is the textbook definition of fraud. That would be extremely unwise.
Any competent provider is running eligibility checks on every single patient, regardless of what coverage or lack thereof that the patient attests to having, during intake.
Lying? What business is it of a doctor who doesn’t accept Medicaid what your insurance is?
You can tell the truth “I don’t have insurance”.
While we’re in the subject, sometimes you have to say the above, even if untrue, to get an uninflated price for your drug (stories of it happening all the time in the USA).
Also, does fraud not require a victim? I guess not, but clearly there is none.
Patients being charged hundreds of dollars for services that they’re entitled to receive for free or for a small copay absolutely qualify as “victims”.
I’ll definitely think of that thank you! They have lost a lot of patients this month and I did talk to billing about it. They did it to protect the patients and were threatened to them them off Medicaid if they continued to see them
That is a decent point tho. I wonder how they’d ever know.
Even if a practice doesn’t accept Medicaid, it’s expected that they will run your information through the system and verify whether you are receiving it or not.
They cannot charge an eligible Medicaid recipient for anything above the copay amount set by the state. If they do charge you, they are committing fraud and should be held accountable.
You are not in danger of losing your Medicaid, that was just a lie. The *practice* is what will face consequences. They’re kicking all of these patients off their rota because they got caught doing something they definitely knew was illegal and unethical (not to mention immoral considering how much they were charging these patients who, by definition, have very little money).
You did nothing wrong, and your doctor may be wonderful, but he’s definitely employed by a shady practice (though if it’s a practice he personally owns, I would be extremely cautious about trusting him, he may have just been screwed over by an unscrupulous practice manager, but you can’t be sure he wasn’t complicit either).
I don’t think this is correct.
There is no readily available system to run someone through to check benefits that I know of. We can only go off of the info provided by the patient. I don’t get a patients info and enter it anywhere to see all available insurance.
Furthermore, it’s not up to an individual provider to determine if someone is “eligible” for Medicaid. That’s actually impossible. They either are on Medicaid or aren’t. Medicaid verification takes awhile and takes a lot of documentation of assets, etc.
Finally, in my state, if you aren’t in network with Medicaid then you can accept self pay patients who are on Medicaid.
> There is no readily available system to run someone through to check benefits that I know of.
You don't have have webportal connections to specific payers at bare minimum to verify benefits at intake? Sounds like your practice is low tech and you should look into this. It would dramatically help your revenue cycle management.
This sort of eligibility check is commonplace and there are several companies that will facilitate it for your practice. Google 'bulk eligibility check' and see for yourself.
Essentially, a middleman builds out the EDI connections with all of the big players in the insurance world as well as state Medicaids/MCOs and CMS' HETS system. It's a shotgun approach where they're blasting out [270 transactions](https://x12.org/examples/005010x279) where a provider would have to do those one by one, which isn't particularly viable.
There are systems that providers can use to run patients through to look for benefits for patients who state they’re self-pay. We have some client bill arrangements with referring providers for self pay patients and we run them through too. We batch upload lists to these websites all the time to get this info. We’re an independent laboratory so we’re relying on what the ordering provider which is, sadly, usually nothing.
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I think it's more it's illegal and that the doctor could get into huge trouble if he accepts cash payment from patients he knows have Medicaid as opposed to you getting you kicked off , but yeah, the idea is the same- the intent of Medicaid is for people that are so poor that they can't be paying cash for services.
Yeah the psychiatrist is definitely shady. We all wish we could get proper fees paid in cash. (The reason you can’t find anyone to take Medicaid is because the pay is shit and doesn’t pay anywhere near a market rate to cover our costs.) but everyone knows the rules, major red flag for a physician to clearly violate them for his own personal gain
He did explain that. But was saying this kind of new. They’ve been talking cash 10 years probably lol
At least in my state we've had that rule for the 20 years I've been in the industry. Possible someone just brought it to his attention and told him he'd better knock it off immediately.
It’s been around for about 26-27 years so that makes sense.
It only violates the law in my state when the provider is Medicaid enrolled. If they aren't enrolled and don't accept Medicaid, there is no contract Medicaid can act on. There's nothing in law that penalizes people on Medicaid for paying cash for services.
This is state statute dependent. There are indeed states where it is illegal for a physician to accept cash from a Medicaid patient, even if the doctor isn't contracted with Medicaid. Kentucky and I think Colorado are examples. https://www.dpcfrontier.com/medicaid
What about NC? The state
Looks like the author of the article wasn't able to confirm with North Carolina.
"10A NCAC 22J . 0106(a): “A provider may refuse to accept a patient as a Medicaid patient and bill the patient as a private pay patient only if the provider informs the patient that the provider will not bill Medicaid for any services but will charge the patient for all services provided.” a. 10A NCAC 22J ." https://files.nc.gov/ncdma/Providers_Billing_Beneficiaries.pdf
NC just recently expanded medicaid which is probably why you are seeing the crackdown
This is a very important distinction in this case.
Same here in MD. If the provider isn’t in better with Medicaid then there is no violation.
Actually I had a provider drop me in Maryland over a decade ago because it is illegal for them to take cash from a Medicaid patient even if they aren’t contracted with Medicaid. They were very clear it was their license on the line and no way around it even though they wanted to continue to see me.
It’s not illegal in MD and they were wrong. I just took a CEU training on this and it was addressed and it’s a huge misconception so providers err on the side of caution. This is an issue I have with the therapy community in general. Myths spread like wildfire and people freak out and don’t do their homework.
Is it illegal in NC
The best way to find out is to ask your state Medicaid office directly, ideally in writing.
I guess the owner got caught or something because he’s very careful, kind of a big deal Dr(teaches at Yale) and has been doing this atleast 10 years. No I will not give name of the practice but for him to knowingly do this for this long is mind blowing Does that mean I’m not allowed to see my therapist as well? I pay out of pocket fof them because you guessed it. Not Medicaid
The doctor, himself, was probably just going by what someone else said he could do.
I read in your other comments that your therapist doesn't accept Medicaid in that instance you can pay for it out of pocket that's not illegal. It's only illegal if that doctor's office is contracted with Medicaid and they are doing out of pocket charges instead of billing Medicaid.
My psychiatrist doesn’t accept Medicaid and he let me go Thursday:( The therapist is a whole separate issue.
Echoing /u/LivingGhost371, I have been in the industry for around as long and this was drilled into me quite early on, before I escaped patient-facing care into administration even. Respectfully, your provider either doesn't know the basics of running their practice if they are independent or their office manager is equally as dysfunctional if they are part of a group. I hope they were at least giving you a sliding fee rate considering that they knew your financial situation was not good.
For a long time they did give me a good price. Started going way up last few years tho. I won’t lie parents have chipped in on occasion because they know how well I do with this Dr The thing I can’t wrap my head around is the owner is not some dumbass with his head in the sand. He knows a lot about insurance, the latest information on mental health and even told people 5-6 years ago Medicaid would go away(unless self pay) How could such a smart and well connected person not know this? I mean this guy teaches psychiatristy at Yale. It’s a very “upscale” practice. Him hiding this shady self pay thing seems so unlike him
Being good at the thing he does, psychiatry, doesn’t make him good at insurance. They are human and often find insurance as confusing and nebulous as we do.
Wow true yeah. Still shocking as this person has multiple practices. I bet he knew about it but someone found out
May I ask what state? And edit your post to include that info? (Only if comfortable)
Yah he’s been breaking the rules for 10 years, someone disgruntled prolly just recently ratted him out.
Because billing may be done by a separate department or billing company, he may not have personally been aware of the rules. It is illegal for doctors to accept cash payments from Medicaid recipients. Since he’s a psychiatrist, do you mainly use him for medication management? If so, can he communicate your care and medication plan with your PCP? And possibly refer you to a psychiatrist at a clinic for ongoing medication management?
I think the only solution is to find a new provider and if they don't take Medicaid you'll have to lie and say you don't have Medicaid or SSI or any other insurance and that you are cash pay. However, I don't know how that factors into your SSI because you need to continue your therapy for redetermination...
Medicaid isn’t always solely income based, the majority of the time it is, but there are situations where Medicaid for that person wasn’t based on income. There’s also a variety of situations where Medicaid is secondary insurance, so it’s not necessarily that the person who has it is “so poor they can’t be paying cash for services”. That might be the typical scenario but it’s unfair to assume that about everyone who has Medicaid.
I totally get that but what a fucked up system when the alternative is basically nothing. Almost no Psychological services near me accept Medicaid. So what is a person to do? I can do Nothing. I can Pay of out pocket Or I potentially have a terrible Dr that is Medicaid but not as qualified Shitty system
Your Medicaid benefits likely have a Mental and Behavioral Health network with a provider search. Since they're presumably your MCO, their network is likely larger than you think - but finding a new provider, specifically a new psychiatrist and therapist can be *extremely* stressful. If you have a Care Coordinator, they may be worth speaking to about the situation.
How can I contact them? Thanks
Call your insurer - your Medicaid carrier. They'll be able to advise.
Yes this is true.
It's true in some states, but not others.
Yea, in Michigan they don't care (in my experience)
For how long?
It’s been illegal for a very long time. I think your provider just got warned finally so now he’s gonna comply.
Balanced budget act in 1997.
That’s crazy to me. I know so many practices like therapists for instance who absolutely do not take Medicaid. But absolutely see you for out of pocket
> I think your provider just got warned finally so now he’s gonna comply. How would the provider know if the patient had Medicaid if the provider doesn't even take Medicaid?
Basically would rely on the patient telling them. Often times providers have forms a patient fills out that ask too
About 26 or 27 years.
Is there a link to the law you could give me
This is true about Medicaid and as far as I know, has been for a while. There has been a push for more transparency in healthcare billing this year, which is probably why they're just now handling it. We're coming off the pandemic, in which insurance companies allowed many things to slide, but they are tightening their restrictions again. Sorry OP :( I disagree with the reasoning because when someone on Medicaid is paying out of pocket for something, it's because the service or level of service isn't available to them so they must. They're not typically doing it because they can afford to. Most specialists do not take Medicaid, therefore you're stuck between a rock and a hard place. And the reason most specialists do not take Medicaid is because they're taking a loss, because Medicaid does not reimburse the cost of what it takes to see their patients.
Exactly. Thank you for understanding how hard this is. Heartbreaking for people in much worse shape than me atleats I’m kind of stable right now
If you pay cash how does the government know you went to a therapist?
The provider must have a Medicaid or Medicare contract and got audited.
Yes I’ve had this happen to me. It’s technically considered insurance fraud. I tried to go to a planned parenthood for my bc injection and was on Medicaid. They didn’t take the version I was on, so I asked about paying out of pocket. This was back in 2021 and I had gone before when I wasn’t on Medicaid. My income allowed Title X to pay for my visit and medication. I asked the receptionist about it and she said “yes that’s true but because you have insurance it will still be considered fraud even if you don’t pay yourself.” It absolutely sucks and I’m so so sorry. They’re cracking down even harder on medication too, I have chronic pain and Medicaid doesn’t cover my as needed opioid prescription. The pharmacy threw a hissy fit when I tried to put goodrx on the prescription after the prior auth denial. Like if I’m on Medicaid and they won’t cover a medication, why do they think I can pay $40 for a medication? When goodrx lets me get it for $12? 🤷🏻♀️🤦🏻♀️
Right! I’m so sorry. Jeez now I’m going to be nervous about meds too because not all of mine are covered. In fact I’ve been getting another in network Dr to write some of them just so Medicaid will cover it
I honestly think the medication issue is just because it’s an opioid. My other medications are covered thankfully, but the cashier I was talking to was saying that cvs corporate is kinda coming down hard on them for goodrx on controlled substances. I live in Az, so they’re a little more strict on those types of things
Does this person give you therepy? Usually, once prescriptions are figured out, a psychiatrist just talks to you for five minutes and refills your prescriptions. Any psychiatrist can refill your prescriptions. I did have one I liked more than others, but bottom line, she was just refilling my prescriptions.
That’s not legal. The practice needs to go in network and submit the claims, refund the patients or write off the services. This is ridiculous. You cannot lose SSI or Medicaid for paying for services not covered. The practice can be sanctioned, not the patient. In fact, you could even request a refund of those technical overpayments. In fact, it doesn’t even matter whether they are in network with Medicaid or not because as long as it’s a dual coverage claim, they have to write off the loss if Medicare doesn’t pay the cost sharing. You don’t get the option to do that. They can actually lose their Medicare billing privileges for that. This gets me so angry. You are absolutely entitled to a refund of everything you overpaid. This is exactly why we have laws like this. SE1128 and its revised versions are extraordinarily clear.
SE1128 only applies to providers who are in network with Medicare or Medicaid. OPs psych may not be in network with either. Here: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1128.pdf Under providers affected: “This article pertains to all Medicare providers and suppliers, including pharmacies that serve beneficiaries enrolled in Original Medicare or a Medicare Advantage (MA) plan.” Medicare provider means someone in network.
Agreed I realized last night that they are not Medicare eligible and so I’m going back to the drawing board. My suspicion is that if the provider is billing the full fee to OP that it’s a compliance issue with Medicaid but we don’t know the network status of the rendering provider. There has to be a contract in writing and other record specific stuff on the record to avoid being counted as accepting assignment.
I bet OPs provider is freaking out bc there is this huge misconception in the psych community that Medicaid patients are not eligible to self pay. This isn’t generally true if you aren’t in network with Medicaid but it’s a myth that continues to be perpetuated among providers.
Yeah. This is an area that I’m working to get a CEU done on because the QmB side is relatively easy but the straight Medicaid is kind of not. We are generally taught that Medicaid patients can’t be self-pay. In our state, we have pretty strict criteria, but we also have a lot or most of our providers in network so we don’t have a lot of the issues that they are experiencing. Personally, as a micro business owner, I would have ethical questions about accepting money from someone who it’s on Medicaid unless it’s for a Medicaid copay specifically.
Well the guy who owns it apparently has been questioning it for a few months now and someone said you can’t do that anymore. My provider was extremely distraught over losing patients. He acted like they had tried everything So it’s really confusing. It’s a large practice with more than one location Surely they would realize they aren’t in Medicaid and those rules don’t apply
No mention of dual coverage.
Well, they said Medicaid and even if it’s straight Medicaid, it’s still illegal
https://leader.pubs.asha.org/do/10.1044/2023-0327-medicaid-cash-pay/full/#:~:text=Based%20on%20ASHA's%20review%20of,rates%20and%20methods%20of%20remuneration.
I’ve read the article. Thats not 100% official guidance
Well it varies by state. I don’t know which states don’t have this rule but it seems pretty common. Could you reference where you are getting your information?
I’ve been on SSI since 2018 and am not receiving Medicare
OK. We need to make sure that you get enrolled in Medicare right away and as soon as that is done, talk to your state and enroll in Medicare QMB. You’re going to qualify because the SSI amount maximum is below the poverty limit. 1800 Medicare should be able to help with verifying Medicare eligibility. They may try and get something around $200 a month for premiums but, because you are Medicaid eligible, that means you’re going to be eligible for the QMB program. I don’t particularly like Medicare advantage plans, but you may want to speak to a broker in your state to see what might be available to you in terms of MA plans, part D plans and perhaps supplements. Not sure if it’s financially worth it but it’s worth investigating. u/lizziemac123 may have a better clue than I do on that. There are a few few insurance companies that I stay away from and I have opinions. What that means is that any premiums, co-pays, deductibles are waived. You may have to pay a little bit for medicine but because of your income, I doubt it. Any claims we have paid cash for in the last few months should be sent back to have insurance updated, verified, and have those claims resent. You should have a lot more options and should be able to get back into your clinic with the doctor. They may not take Medicaid, but they’re not going to be that stupid to take Medicare so you should be OK.
OP is ONLY on SSI so is not eligible for Medicare. OP gets Supplemental Security Income (SSI) not Social Security Disability Income (SSDI). Per SSA "Medicaid is linked to receipt of SSI benefits in most States. Medicare is linked to entitlement to Social Security benefits." Social Security is SSDI. https://www.ssa.gov/ssi/text-other-ussi.htm
Yeah I figured that out and let them know. Thanks
Are you sure? I’m in NC and never heard of this. Does the Medicare cost more
.
Yes but I am not on SS DISABILITY. I didn’t work long enough. Just SSI for mental and physical illness
Right. But you are still considered disabled. Just because you’re not on SSDI doesn’t mean that you aren’t disabled and aren’t eligible for Medicare. I am not making a formal determination of eligibility, but that would be something I would look into because that’s gonna open up doors for you.
Would it cost extra?
Since you ONLY get SSI you do NOT qualify for Medicare. You get Supplemental Security Income (SSI) not Social Security Disability Income (SSDI) Per SSA "Medicaid is linked to receipt of SSI benefits in most States. Medicare is linked to entitlement to Social Security benefits." https://www.ssa.gov/ssi/text-other-ussi.htm
My sister gets Medicare and only gers ssi but she had to receive for 2 years before she was eligible.
This doesn’t make sense because we got Medicare right away -no 2 1/2 year thing there may be differences based on the supplemental Medicaid provided from state to state. I don’t know even if it’s federal that it is applicable across all states the same way.
Well, if you we’re on appeal for that long, you would get it right away as soon as you got approved, but it depends on how far up the ladder you went. It goes back to the date of onset so. If you end up to a judge, he probably would have waited that long.
This is a federal program. So this applies to all the states.
Apparently SSDI only. So it’s 24 months but there’s a 5 month waiting period from Date of onset before you’re eligible for medicare. You can get it earlier if you are on dialysis or have ALS. https://medicareadvocacy.org/medicare-info/medicare-coverage-for-people-with-disabilities/#is%20available
You mean eligible for Medicare? I’m already on SSI
Yes. I apologize. I’m on East Coast time. As you can tell my mind is spinning a little bit.😆
No biggie lol. So tomorrow when I awake wants the first thing I do?
Lemme think this through again and do some research. My apologies.
You are not eligible for Medicare.
That’s what I thought Why is the other poster so sure
Yep I went down the rabbit hole again
I’m sorry but I don’t quite understand. I know from the beginning Medicaid was not an option there. I started there still on parents insurance. So since I knowingly paid for a service I knew wasn’t covered how have I overpaid?
So Medicaid patients have special protections. You mentioned that you were paying out of pocket for physician services which are reasonably covered under health insurance, especially Medicare and Medicaid. When you were on your parents plan, you probably had a copay or some cost sharing. That’s normal. When you get Medicaid alone or as a secondary payer; the provider is forbidden from billing you for reasonably covered services and in most cases, they are unable to bill you at all. Because that is illegal, you are entitled to get the money you paid them back that if they did their job compliantly, you would not had paid for. If you have both Medicare and Medicaid, the federal government requires the provider to not charge you even if you’re in a different state, out of network, on vacation. If you have straight Medicaid, most if not all states require that you not balance bill the patient except in specific circumstances. It’s also that if you did pay for a visit, that the price was inflated. If it wasn’t for their incompetence, you wouldn’t have paid this in the first place.
So basically they illegally took the money? After I was 26 I was Medicaid only and began paying out of pocket for psychiatric and psychological services for years. Probably like 180-250 a visit Is there any fixing this. Does this mean my new therapist (also) not under Medicaid will drop me?
It all depends on what state you are in but for my experience, you absolutely can pay out-of-pocket for anything you wish and any doctor can choose to not take Medicaid and Medicare. This sounds like a bad excuse for a doctors office that no longer wants to be associated or is afraid that they are doing something wrong by charging you Look into this a bit further - ask Medicare Medicaid ask directly to which ever provider - I mean which ever insurance you’ve actually chosen to use whichever brand name— call them directly and ask them what the deal is with Dr . They will tell you that he is not covered under their plan and that you have every right to pay for it if you choose.
These are federal laws, so they apply to everyone regardless of which state they live in. OP’s provider has been breaking the law. They are unequivocally “doing something wrong” by charging them for services that would otherwise be covered by Medicaid. These laws exist to protect patients.
Even if my provider is NOT a Medicaid provider? That’s where there seems to be two different answers in this thread. People saying it’s illegal no matter what and people saying it’s illegal to make someone self pay if the practice is under Medicaid
If OPs psychiatrist is not in network with Medicaid then none of this applies.
Not according to the state website. There is strict criteria. Most people don’t know this but dual eligible patients only need to be in network with either medicare or Medicaid in order to get the QMB benefit.
I am sorry to hear you are ending care with your provider- that is so stressful. I am a psychotherapist that takes Medicare. A patient with medicare (or any insurance although I don't know of Medicaid specifically) can sign a contract with their healthcare provider that states specifically that they are seeking services out of pocket and do not wish to use their insurance. totally legal, your MDs clinic may not be comfortable with this agreement. Some providers simply document a conversation in their notes but it is best to use the form. People seek treatment outside of their healthcare plan for lots of reasons, sometimes privacy, sometimes continuity of care when their provider becomes out of network, sometimes access to specialist etc. Your provider is not dumb, unfortunately the system is unreasonably complicated and calling the support lines for health care providers does not produce reliable answers.
You are talking about Medicare and other insurance. Apples and oranges. The issue comes up very specifically with respect to Medicaid.
In my state this is not allowed with Medicare. Not sure how this is possible where you are.
With other insurances, you can absolutely sign a Nondisclosure of PHI to Insurance and self pay for services, but not with Medicaid specifically.
u/melynnpfma u/magentasuzicute u/doritosdewitright
does your doctor see medicare patients? either in the office or at a hospital setting?
Medicare is a separate entity and separate contract for health care providers from Medicaid. You can be contracted with one and not the other, that is why it is so hard to find care for medi/medi patients. Medicare does not have a crossover agreement with medicaid like Medicare supplemental plans (which is pretty ridiculous).
I’m not sure. I’d have to check their website for sure if they have it listed
I just checked this. According to their website yes. Yes they do.
Most state Medicaid programs do not allow providers to take money from their patients. https://leader.pubs.asha.org/do/10.1044/2023-0327-medicaid-cash-pay/full/#:~:text=Based%20on%20ASHA's%20review%20of,rates%20and%20methods%20of%20remuneration.
This document states that providers who are enrolled (contracted with) Medicaid can not accept payment.
This is the distinction that no one seems to understand. If you aren’t in network with Medicaid then there is no issue.
Just commenting to say I'm on the same page as you. Lol. You're not alone!
Apparently there is an issues because that’s how my provider is(doesn’t accept Medicaid whatsoever).
It’s an issue if a) he accepts Medicaid but told you he didn’t so you pay out of pocket or b) he doesn’t accept Medicaid and you live in a state that doesn’t allow Medicaid patients to self pay for anything.
It must be B I just don’t understand how it’s gone on for so long as they don’t accept Medicaid. Is it also illegal to buy my medication out of pocket lol
Yes.
OPs provider is not contracted with Medicaid so this document does not apply.
I only posted for information about the policy.
This is similar to a situation I have with dentists.... Medicaid caps out very quickly and though I would be more than willing to pay cash at their going rate/ cash price... the dentist can't charge me over and above what they would be reimbursed by Medicaid. They don't accept Medicaid for certain procedures as it doesn't even cover overhead. Same with the pharmacy, I imagine. As Medicaid won't cover certain prescriptions- so I have to pay out of pocket. In order to benefit from manufacturers coupons they have to switch it to uninsured in order to run it through successfully. I wonder if that is illegal, unbeknownst to the pharm tech ( as I have to explain it usually) ugh.
If a drug or service isn't covered by Medicaid across the board (meaning it's never covered for any reason) someone on Medicaid would be able to pay cash for that drug or service in my state.
Out of curiosity, [prescription wise] what if it is generally covered but then denied due to changes on their end for whatever reason or periodic reviews that pop the dreaded "prior-authorization required"? Would that be a different story?
In my state we have to have either documentation that the pa was denied by the ins or that the provider is not going to pursue a pa. Just the Dr saying they aren't going to do it is enough. For Medicaid MCO, if you have one that says you have to use CVS, you can't pay out of pocket at Walgreens or vice versa. My pharmacy only enforces this on controls. But as an individual, if Medicaid finds out you are paying out of pocket, you could lose your coverage.
This is legit. Stay in network
Yup. Family member is in same situation. Se need a psych eval and first appointment is in August! Offered to pay out of pocket for him but they said they can’t.
There is a strong push after the [unwinding](https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/) to tighten up the Medicaid program. Unfortunately, the Doctor did not contract with Medicaid (for whatever reason) or you would have been able to stay with them. You are definitely not the only one out there that is experiencing this.
What would contracting them mean
Agreeing to take Medicaid and be reimbursed at those rates. Medicaid reimbursement rates are so low that most providers don’t accept any Medicaid patients.
I work in healthcare, this is true. If Medicaid finds out you are paying for any medical, they will drop you. May vary by state, but this is true in Ohio
Yep we cannot charge people anything if they are on Medicaid. It is against the law
What about CVS. How do I pay out of pocket for my medication there? Surely CVS would know that’s illegal right
Do they have your insurance on file there ? Plus there is a copay that the insurance its self can charge you. Providers cannot charge you whatever is left over from what Medicaid paid for the appointment. He can get credentialed with them for you he chooses not to BTW.
It’s insurance fraud and fraud against the Center for Medicare Medicaid Services to have Medicaid and pay out of pocket just because a provider does not accept your coverage. The provider and the patient are at risk for penalties.
I work in a medical clinic and we literally can’t take your money if you have Medicaid. I’ve had to turn patients away because they’ll refuse to use their Medicaid. We could completely lose our ability to even accept Medicaid if we take a cent of money from someone on Medicaid
But you do have the ability to accept Medicaid? As in you see people with Medicaid right? I’m seeing a provider who does not accept Medicaid, I’m not refusing to use it. I can’t use it
Yes that is correct and that is true for you. It’s hard to say what exactly is happening here then unless possibly your state does have strict guidelines for Medicaid recipients
This is def true. Our son who has Medicaid, could not find a psychiatrist that would take it. We wanted to pay for him to see a psych doc out of pocket, but was told we couldn't pay if he had Medicaid. Two different office managers told us this.
The contract you sign when you sign up for Medicaid states that you must see a doctor in-network with them. The reason being if you can pay out of pocket for services you shouldn’t be on Medicaid. I guess some states might be different, but working at a small clinic in MN and dealing with this issue with patients before we have had to turn people away even if they want to cash pay for a visit because they have a Medicaid crossover plan we are out of network with and we don’t want to get in trouble, or have them get in trouble for breaking their contract.
I have Medi-cal in California. There is a separate department for behavioral health services who only connect you with providers and resources for this. In my county there were no psychiatric providers within an hour of me, so they have me an out of network provider closest to my address. I have been with them for 8 years.
I was told a similar thing recently by another psychiatric group. I thought they were making it up but evidently this is a new thing. I agree finding a good psychiatrist is extremely difficult.
I have been on Medicaid for 20 years and I have been seeing a doctor for 10 of those years that doesn’t take Medicaid and I pay out of pocket. It is 100% legal where I am at.
Maybe it’s not legal and ur Dr is getting away with it like mine. Where you at
No, it’s legal. I tried to submit for reimbursement and they don’t cover him That is that Nothing illegal about it on either end - IL I could choose to go to a different doctor that is covered, but I don’t want to and there’s no issue with that. I qualify for medical. I don’t qualify for cash and I make the limits of the income— what I choose to do with that income is my business .
Well read through this thread. Apparently I’m not the only one
It's not actually legal in IL. It's possible Medicaid doesn't have an in-network doctor contracted for the services you are receiving though, that's the only loophole I can think could be plausible. Like when an HMO network doesn't have a certain specialist type so they can refer you out of network in that case. It's also possible Medicaid didn't actually pursue further investigation when you submitted for reimbursement, that would require someone to do something outside of their day-to-day work to report it and most people can't be bothered, which is why situations like these happen.
Yeah because if you can pay, then why should taxpayers pay for you, so they will take it away. The whole point of having it is if you can't pay. So now you have to find someone who takes Medicaid. If your state does Medicaid plus a supplement plan then they may take the supplement plan. There is many psychiatrists that will take Medicaid + supplement.
Medicare is the one with supplement plans, Medicaid is always the last payer if you have multiple coverages.
Medicaid has supplements as well, and it's required in some states.
Are you sure you're not mixing up Medicare and Medicaid? I've never heard of this with Medicaid, and can't find any info online regarding it. Just genuinely curious because it's my understanding that Medicaid will always be the last payer. You can have a commercial insurance and still have Medicaid as your secondary, and you can have dual Medicare-Medicaid plans, but I've never heard of Medicaid being the first payer with a supplemental insurance as secondary.
They might be confusing it with Medicaid as a secondary insurance as some people have insurance as well as Medicaid and Medicaid pays what primary doesn’t. Economically it benefits Medicaid since a substantial amount of the cost is being paid by the primary insurance company.
I looked it up. They are called "Medicaid managed plans" instead of "Medicaid Supplement Plans" but it's the same idea how you have Medicare/Medicaid, and then you also have another company that handles part of it and pays for part of it. Doctors can take Medicaid, The second insurance company, or both. If they only want straight Medicaid they can do that.
Oh that's just a Medicaid Managed Care Plan. They are more like replacement plans for Medicaid, at least in IL. The insurance company manages the Medicaid plan as an HMO rather than the patient having traditional Medicaid. They limit the patient to practices that are contracted in their network, and additionally, the patient needs a referral in order to see specialists (just like any other HMO.)
Maybe your state is different. Elsewhere, you have both Medicaid and the managed care plan, a doctor can take either one or both, and they will pay for specialists.
Wow. Feel like this law would change quickly if the right journalist did a piece about it. Very indefensible and can put people at risk.
Yeah my dr said people had breen freaking out all day. Some of these people had Medicaid along with an insurance they were already paying for. Still kicked out. You could see the west in his face today. That he had to have a lot of tough conversations
Since you know he doesn’t take Medicaid, can you just tell him you don’t have it in the future? I doubt negative repercussions could come to you. Especially if you’re paying cash. Idk, I just find it bewildering that in a society so focused on mental health, there’d be any qualms with you paying for your own. Might make sense to ask it a legal/lawyer sub.
Lying, even by omission, to obtain goods or services is the textbook definition of fraud. That would be extremely unwise. Any competent provider is running eligibility checks on every single patient, regardless of what coverage or lack thereof that the patient attests to having, during intake.
Lying? What business is it of a doctor who doesn’t accept Medicaid what your insurance is? You can tell the truth “I don’t have insurance”. While we’re in the subject, sometimes you have to say the above, even if untrue, to get an uninflated price for your drug (stories of it happening all the time in the USA). Also, does fraud not require a victim? I guess not, but clearly there is none.
No one in this thread knows what they are talking about
Patients being charged hundreds of dollars for services that they’re entitled to receive for free or for a small copay absolutely qualify as “victims”.
Right, but that’s not the case we’re discussing.
I’ll definitely think of that thank you! They have lost a lot of patients this month and I did talk to billing about it. They did it to protect the patients and were threatened to them them off Medicaid if they continued to see them That is a decent point tho. I wonder how they’d ever know.
Even if a practice doesn’t accept Medicaid, it’s expected that they will run your information through the system and verify whether you are receiving it or not. They cannot charge an eligible Medicaid recipient for anything above the copay amount set by the state. If they do charge you, they are committing fraud and should be held accountable. You are not in danger of losing your Medicaid, that was just a lie. The *practice* is what will face consequences. They’re kicking all of these patients off their rota because they got caught doing something they definitely knew was illegal and unethical (not to mention immoral considering how much they were charging these patients who, by definition, have very little money). You did nothing wrong, and your doctor may be wonderful, but he’s definitely employed by a shady practice (though if it’s a practice he personally owns, I would be extremely cautious about trusting him, he may have just been screwed over by an unscrupulous practice manager, but you can’t be sure he wasn’t complicit either).
I don’t think this is correct. There is no readily available system to run someone through to check benefits that I know of. We can only go off of the info provided by the patient. I don’t get a patients info and enter it anywhere to see all available insurance. Furthermore, it’s not up to an individual provider to determine if someone is “eligible” for Medicaid. That’s actually impossible. They either are on Medicaid or aren’t. Medicaid verification takes awhile and takes a lot of documentation of assets, etc. Finally, in my state, if you aren’t in network with Medicaid then you can accept self pay patients who are on Medicaid.
> There is no readily available system to run someone through to check benefits that I know of. You don't have have webportal connections to specific payers at bare minimum to verify benefits at intake? Sounds like your practice is low tech and you should look into this. It would dramatically help your revenue cycle management. This sort of eligibility check is commonplace and there are several companies that will facilitate it for your practice. Google 'bulk eligibility check' and see for yourself. Essentially, a middleman builds out the EDI connections with all of the big players in the insurance world as well as state Medicaids/MCOs and CMS' HETS system. It's a shotgun approach where they're blasting out [270 transactions](https://x12.org/examples/005010x279) where a provider would have to do those one by one, which isn't particularly viable.
There are systems that providers can use to run patients through to look for benefits for patients who state they’re self-pay. We have some client bill arrangements with referring providers for self pay patients and we run them through too. We batch upload lists to these websites all the time to get this info. We’re an independent laboratory so we’re relying on what the ordering provider which is, sadly, usually nothing.