Medicaid is public health insurance program that aims to provide healthcare coverage to individuals or families with low income and cannot afford private health insurance; people with disabilities, elderly or pregnant women. Medicaid is regulated and funded by the federal government and states.
Medicaid reimbursement refers to the payment given directly to the provider for a service rendered. Medicaid sets the amount of reimbursement that each provider will get. The Medicaid provider must accept the amount as full payment for the service rendered.
Medicaid reimbursement types include fee-for-service and managed care arrangement. Fee-For-Service is a type of Medicaid reimbursement that pays the provider a set amount for the services that was rendered. This type of reimbursement allows the insured to seek medical help from a physician of his/her choice. But not all medical practitioners are willing to accept patients under the Medicaid program.
In managed care arrangement, the insured must consult with an in-network physicians or specialists who are paid according to the set rate that was established by Medicaid. Under managed care, out-of-network physicians may be paid a lesser rate granting that they will agree on the rate that was set.
There are certain rules that need to be followed by medical providers when billing Medicaid for the services they have rendered. First, they should be aware of the maximum amount that they can reimburse from Medicaid.
Second, Medical providers are only allowed to bill Medicaid with services rendered that are considered medically necessary. They must provide proper documentation and diagnosis of the service they have provided together with their billing statement.
Medicaid also allows the insured to reimburse a portion of what they pay for prescription drugs. This portion is normally set from the start. Medicaid, however, does not usually pay for expensive, non-generic drugs unless authorization from the physician is acquired.
In order to get reimbursement from Medicaid, the medical provider must submit a claim form that states the kind of treatment or procedure or service that was provided to the insured. There is a service code for each specific type of service. The service rendered must be billed with the appropriate service code. The service code was provided by Healthcare Common Procedure Coding system. If uncertain about the service code for a specific type of service, it is best to consult with Medicaid.
Medicaid reimbursement varies from state-to-state. Each state has their reimbursement rate for medical services provided under Medicaid. Providers must be willing to accept the reimbursement rate set by Medicaid. They cannot charge the patient with additional fees outside of the reimbursement rate.
Although issues about Medicaid reimbursement are typically addressed to the medical provider, the insured should at least have the basic knowledge of how this works so that there will be no surprises when they seek medical attention.