My mother in a nursing home received a bill from her primary dr that visits her in the nursing home for the balance after Medicare and Medicaid paid. We are in Florida. Are they able to do that? Have been calling Medicaid office but wait time is horrendous! Help please!
but...if the item(s) were not approved by Medicare, then the patient must pay for it out of pocket.
for example....if a patient is given a medication in the ER that is actually an over the counter drug (like ordinary aspirin), the patient will be billed for it cause Medicare doesn’t approve it.
but...if Medicare paid their share, then that means that Medicare approved the bill. Secondary insurance (in this case Medicaid) covers the rest. The doctor is not allowed to bill the patient unless Medicare doesn’t approve the bill...in which case Medicare would have paid no part of it. When a doctor accepts Medicare/Medicaid.....it means he accepts their payment as payment in full.
Medicaid does not send out statements, they just pay the balance.
I think ur going to find is Moms PCP does not except Medicaid.
In my experience that is very unusual. For my mom & mil once they were residents of the NH, all health care oversight and decisions flowed thru the medical director of the NH. They wrote all orders for care often basing how things / scheduling are to be done depending on staffing. And RXs - written by medical director- got filled thru whatever 90/120 day blister pack script service the NH was contracted with. No outside docs inserting their directive / orders / prescriptions into the residents care plan as they wanted.
Unless there was something extraordinary going on, like specialized oncology care or they were recovering from surgery with post surgical care written into their admissions. My mom had the latter situation & it involved a eye RX x 3 daily for abt her first mo, they were aware before admission & ok for it, the medical director wrote the identical script as mom’s retinal doc., so all dispensed within their system. No outside RXs coming in to be dispensed.
Before too too much time goes on, I’d clearly speak with the DON (director of nursing, who imo is the goddess & power center for a NH) as to IF an outside MD care plan can at all work for how this facility runs. Then contact that MD to see if they accept Medicare & Medicaid. If not, they will bill your mom or you if you signed off to be financially responsible.
I’d bet, as others posted, her old doc will be viewed as “out of network” for care now that she is in a NH. Sometimes there’s a lag time in the insurer finding this out. But if so, insurance can clawback payments made. This can get ugly as they will bill mom/ you at full private pay rate. Really find out ASAP what is allowed for outside care directives.
I will just write the dr staff and hope that will be the end of it!!
Thank you so much for your answers. This is great to have a place we can ask for help!!
I would write a letter Confidentially to the Doctor telling him that his billing office has not returned the 4 calls you made. That you feel the balance due is an error on billings part because Mom is now on Medicare/Medicaid. And since he is a participant, there should be no balance due.