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When your out-of-pocket patient uses Medicaid to pay for prescriptions

  • 1.  When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-14-2017 20:50
    Hello all,
    How do you address the issue where an out-of-pocket patient in a cash-only practice seeks to pay for prescriptions with Medicaid?  Today, I was called by the pharmacist who informed me that Medicaid will not pay for my patient's prescription because I am not enrolled with Medicaid. Has anyone ever experienced this situation?

    Thanks in advance for your feedback.

    Ann-Marie Anderson



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    Ann-Marie Anderson
    Psychiatric Momentum LLC
    Bethesda MD
    201-738-5963
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  • 2.  RE: When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-15-2017 06:13
    Medicare and Medicaid offer the option for physicians to "enroll" but only to the degree that they will cover prescriptions, referrals, and orders made by you despite you still being considered a non-participating professional. This sort of partial enrollment is the only way I know of for these patients to get their prescriptions filled when written by a doc who doesn't take insurance. There is an application for Medicaid and a separate application for Medicare though both applications are referred to as "Enrollment for Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals".

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    Elizabeth Weeks
    Apple Tree Medicine, PLLC
    Williamsburg VA
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  • 3.  RE: When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-15-2017 09:17
    Thanks so much! This is more information than I received from the Medicaid office this morning.

    Ann-Marie

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    Ann-Marie Anderson
    Psychiatric Momentum LLC
    Bethesda MD
    201-738-5963
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  • 4.  RE: When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-15-2017 13:21
    Interesting !  In some states  one cannot see Medicaid patients and have them pay cash- illegal  I am told( is that true? Never saw it in print I admit)
     so,  it would be obvious they would try to get their prescriptions paid for who wouldn't   but the prescription coverage is connected to who wrote for it?? I am not helping you I am sorry  Let us  know
    The system  gets  more bizarre daily   I confess I am at my wits end


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    Jean Antonucci
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  • 5.  RE: When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-16-2017 06:37
    I've also understood it that with my cash-only practice I'm not allowed to charge a Medicaid patient for services that are covered by Medicaid.  I have only a handful of these patients, so I've made the decision just not to charge them for their visit.  I have not had any problem ordering labs or prescribing medications for these patients.





  • 6.  RE: When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-17-2017 09:02
    The rules are different for medicaid and Medicare:

    For Medicare, you as the provider have to “opt out,” which an affirmative step you must take. A quick google search for "Medicare opt-out" will reveal a wealth of resources. You can either opt-out and see medicare patients on a cash basis, or bill medicare for covered services for medicare patients. There is a lot written on this on the internet. Being a medicare provider (remaining in the program) and accepting cash from a medicare patient for services opens you up to big-time risk.

    For medicaid, which is a state program, things are a bit more complicated, and less straightforward. As has been mentioned, you can have an “ORP” status, which essentially allows you to order supplies, referrals, and medications for medicaid patients, but otherwise not be involved. In California at least, there is nothing that prevents you from privately contracting for services with a medicaid patient (cash pay). However, this may vary state-to-state. In California, Medicaid does not require an opt-out, as Medicare does.




  • 7.  RE: When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-18-2017 22:27
    IF you participate with Medicaid or a managed-care MCD product the patient is in, you need to have them sign an agreement before you do private pay.  If you don't par in Medicaid or their managed-care MCD product, there's no problem.

    Balance Billing: Is It Legal? - AAPC Knowledge Center

    https://www.aapc.com/blog/34357-balance-billing-is-it-legal/
    Apr 8, 2016 - For Medicaid providers, balance billing is legal:
    If the physician does not have a contract with the insurance plan.
    If the services are non-covered services (think cosmetic surgery) by the insurance plan.
    If the patient chooses to opt-out of using their insurance and be a self-pay patient for any particular service.

    In California, MediCal pays $24-35 for an office visit, so you'd have to be plumb loco to participate in MC as a private practice.  MCD pays FQHCs ~$160/visit, no matter what they're for.
    Just FYI.

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    Peter Liepmann MD FAAFP MBA
    My mission is to fix US health care www.PCMHpcc.com
    Bakersfield CA
    5183026006
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  • 8.  RE: When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-19-2017 04:49
     Not the same in every state. 



    Kathleen Saradarian,  MD
    Quality Family Practice
    Branchville, NJ 

    Sent from my Verizon, Samsung Galaxy smartphone





  • 9.  RE: When your out-of-pocket patient uses Medicaid to pay for prescriptions

    Posted 12-16-2017 11:31
    Thanks for your response.  You bring up a good point.  There are so many land mines in this area of heath care law.

    I think that since the facts and circumstances would be different for each provider/situation, criminal or civil liability would be determined after a fact-based analysis. I also think that the outcome would be depend on several things such as whether there is a financial relationship between the cash-only provider and the pharmacy, lab etc. where he/she referred the Medicaid/Medicare patient?

    I have not heard of it being a criminal offense to charge cash to a Medicaid or Medicare patient, if the provider does not bill any other federal or state insurance program (Medicaid) for services for any other patients. If the provider bills federal or state programs for other patients, the free service or lower cost out-of-pocket, reward or down-coding, etc. for another patient could be perceived as remuneration under the Anti-kickback statute. Remuneration, if not de Minimis could be perceived as an inducement if intent can be proven.  I think that on its face, It could be perceived that the provider who gives free service to a Medicaid/Medicare recipient could be making up for the free services by billing the federal/state program in some other way. It also depends on whether there are any Safe Harbors.


    "The Anti-kickback (AKS) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. See section 1128B(b) of the Social Security Act. Where remuneration is paid purposefully to induce or reward referrals of items or services payable by a Federal health care program, the anti-kickback statute is violated. By its terms, the statute ascribes criminal liability to parties on both sides of an impermissible "kickback" transaction. For purposes of the anti-kickback statute, "remuneration" includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind"

    That being said, this is just my opinion, not legal advice. I did a quick search among HHS OIG Advisory opinions and I have not yet found any fact pattern that fits my situation. A more thorough review may yield other results.

    In the meantime, I will check with a few experts in the field and get back to you.

    Sorry for my long comment!


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    Ann-Marie Anderson
    Psychiatric Momentum LLC
    Bethesda MD
    201-738-5963
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