Medicaid to Clean Up Dual Eligible Mess

State Medicaid officials say they will fix the mistakes and reprocess the claims of physicians incorrectly paid $0 for treating patients eligible for both Medicaid and Medicare, known as "dual eligibles." The Texas Medical Association brought the problem to their attention on behalf of physicians and their patients who were threatened with losing their health care because many physicians across the state faced financial ruin.

"Medicare crossover claims that were affected by the incorrect reimbursement of $0 for the first detail line item listed on the claim will be reprocessed," the Texas Medicaid and Healthcare Partnership (TMHP) said in a statement posted on its website [PDF]. "After these claims have been reprocessed, providers may receive additional payment, which will be reflected on future Remittance and Status (R&S) Reports. Claim details that received a correct reimbursement of $0 will not be reprocessed."

The TMHP statement says it identified four issues:

  1. Some professional and outpatient hospital Medicare crossover claims may have received an incorrect reimbursement of $0 for the first detail line item listed on the claim.
  2. Some anesthesia claims were denied incorrectly because of a change in how anesthesia minutes are reported in the HIPAA 5010 format.
  3. Claims may have been rejected incorrectly because Medicare-only information was transmitted to TMHP or information was not transmitted to TMHP in the appropriate format or location.
  4. Crossover claims may be denied because of an invalid performing provider.   

For additional information, read the statement on the TMHP website [PDF].

TMHP also said that for dates of service on or after Jan. 1, 2012, if the Medicare payment is less than the Medicaid allowed because the patient has not yet met the yearly deductible, coinsurance and deductible reimbursement for Medicare Part B and Part C professional and outpatient facility crossover claims may be paid at the lesser of the following:

  • The coinsurance and deductible payment, or
  • The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service

TMHP added that some portion of the annual deductible for Part B claims will be paid if the service is a benefit of Medicaid and Medicare does not make a payment. If the Medicare payment equals or exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid will not make a payment for the coinsurance and deductible.

For more information, see Changes to Medicare Crossover Claims Processing and Reimbursement Effective January 1, 2012 [PDF], posted on the TMHP website in December, or call the TMHP Contact Center at (800) 925-9126.

All of this stems from a cost-saving move the Texas Legislature ordered in which HHSC will not pay coinsurance and deductible payments for Medicare Part B services for dual-eligible patients when Medicare's payment exceeds the Medicaid allowable for the same service.  

Several serious Medicare and Medicaid computer errors compounded the situation.  

A trio of computer glitches were identified that resulted in claims paying $0 during the patients' annual Medicare deductible period, even though physicians should have been paid up to the amount Medicaid would have paid for the service if the patient weren't covered by both Medicare and Medicaid. One of the problems stemmed from a processing error in the state's Medicaid claims payment system. In the other, state and federal computers were not talking to each other properly because of problems tied to the new national rule requiring physicians, providers, and public and private insurers to use HIPAA 5010.  

TMA is calling on state leaders to take emergency action to help these patients and the doctors who care for them.  

Javier Saenz, MD, is a Rio Grande Valley family physician who cares for many these patients. They make up about half of his practice. Since January, he's treated them as always, but has received no Medicare payments and very little in payments from Medicaid. As a result, he is exhausting personal savings and turning to bank loans to make payroll and keep his medical practice open to serve his patients. He doesn't know how long he can hold out.  


Action, March 15, 2012


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    Please include in your legislative arguments for dual-eligible patients that the Managed Care Organizations are keeping state funds for profit given that the money they are receiving is not being used to pay Doctors for the 20% balance which has to be adjusted and written off as a loss for practices. Yet they want Doctors to sign their "Long Term Services - Star Plus Waiver Program (SPW)" forms to provide patients with services in their homes. These services include Personal Care, Nursing Care, Medical Equipment, Installation of Ramps, etc. This does not make sense, Doctors carry the liability for home health, DME equipment, etc. without payment for the "Dual Eligible" population. If the money they recieve per patient is not being used for Doctors then their profit margins will continue to increase. So who benefits in the end?

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    As an ER physician now, I am seeing patients who tell me that their physician/consultant will no longer be able to see them because of this "dual elligibility" problem. When I lived in NY 20 yrs ago, they tried this scheme there, too. Back then, we coped by trying not to be the first provider to bill for that patient, but today that would be difficult with electronic billing systems. Eventually, it was taken to court and the State lost. Is TMA planning to contest this in the courts? This incredible onslaught of changing rules, regulations, billing issues and so forth can only further discourage all but most naive enter any field of medicine...

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