Balance Billing Medicaid Members Prohibited
Balance Billing Medicaid Members Prohibited
Utah Medicaid is reporting an increase in balance billing referral cases to the Utah Office of Inspector General (OIG). Balance billing Healthy U Medicaid members, or any other Medicaid managed care organization (MCO) member, is a direct violation of your MCO or Medicaid contract.
What You Need to Know
- If a member has both Medicaid and coverage with a responsible third party, do not collect a copayment that is usually due at the time of service.
The following statement is available in the Healthy U section of the U of U Health Plans Provider Manual:
"Aside from state-mandated patient responsibilities, such as copayments, coinsurance, and non-covered services, healthcare providers who agree to treat Medicaid patients, such as Healthy U members, are prohibited by federal law from billing Medicaid patients directly for covered services. Additionally, providers should not bill Healthy U members for any amount in excess of the contractually agreed-upon allowed amount paid by U of U Health Plans for covered services, and the provider must accept Healthy U’s payment as payment in full.
Failure to abide by state billing rules and regulations and/or Healthy U Policies and Procedures may result in claims being denied for payment. In such cases, the provider is prohibited from billing the member. Refer to the Utah Medicaid Provider Manual for additional rules and regulations."
Billing for Non-Covered Services
Utah Medicaid allows billing a Medicaid member only in limited circumstances, including non-covered services, spenddown medical claims, Medicaid cost sharing, and broken appointments. Detailed requirements are outlined in Section 3-5, Exceptions to Prohibition on Billing Members, of the Utah Medicaid Provider Manual.
A provider may bill a Medicaid member for a non-covered service only when all of the following conditions are met:
- The provider has an established policy for billing all members for services not covered by a third party (the charge cannot be billed only to Medicaid members).
- The member is advised prior to receiving the service that Medicaid will not pay for the service.
- The member agrees to be personally responsible for payment.
- The agreement is made in writing between the provider and the member and includes the service being provided and the amount the member agrees to pay.
We appreciate the services you provide to our Healthy U members. If you have questions about this clause in your Healthy U or Utah Medicaid agreement, please contact your provider relations consultant or a Medicaid representative.
Reference
- Medicaid Information Bulletin: May 2024, 24-30 — View PDF
- Utah Medicaid Provider Manual, Section 3-5 – Exceptions to Prohibition on Billing Members — View Manual