Cash pay for medicaid patients who's injections are denied

[Painologist]

Does anyone know if it is a breach of your medicaid contract to offer patients a cash pay option for an injection such as a LESI or TFESI if medicaid denies the prior-authorization?

For example, I just had Meridian deny a 2 level TFESI on a patient because he had a prior epidural done 8 months ago by a different doctor that didn't help. I offered the patient the option to pay cash for the injection ($300) and bypass insurance and they agreed.

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[MD87]

From what my business office says, if a patient doesn’t have insurance OR if they have insurance but insurance denies it, you can have them pay cash.

 

[Laryngospasm]

Used to do this at my private practice.. unfortunately cost prohibitive at the hospital as I don’t control pricing.

 

[MitchLevi]

Does anyone know if it is a breach of your medicaid contract to offer patients a cash pay option for an injection such as a LESI or TFESI if medicaid denies the prior-authorization?

For example, I just had Meridian deny a 2 level TFESI on a patient because he had a prior epidural done 8 months ago by a different doctor that didn't help. I offered the patient the option to pay cash for the injection ($300) and bypass insurance and they agreed.

Did you do a P2P?

 

[bedrock]

If a federal insurance procedure gets denied….which would have paid crap anyway….I’m certainly not to spend more uncompensated time doing a P2P.

Straight to cash pay only at that point.

 

[NJPAIN]

This is a great question. It would be nice to have a definitive answer. It would make so much more sense to offer cash pay only rather than spend thousands on the BS involved to support a request for independent review or Fair Hearing to get paid next nothing for the procedure.

 

[Painologist]

If a federal insurance procedure gets denied….which would have paid crap anyway….I’m certainly not to spend more uncompensated time doing a P2P.

Straight to cash pay only at that point.

Exactly. I finally had time to do a P2P 2 weeks after being denied and found out after being on the phone for 17 minutes that I missed the 10 day window to do P2P and now only have the option to mail in an appeal letter. At this point I told the patient that due to their insurance their options are cash pay or no procedure.

 

[runfastnow]

As long as you charge the same to everyone regardless of insurance for procedure you can offer cash price. We do 1.5x Medicare rate for cash pay patients.

 

[drusso]

Does anyone know if it is a breach of your medicaid contract to offer patients a cash pay option for an injection such as a LESI or TFESI if medicaid denies the prior-authorization?

For example, I just had Meridian deny a 2 level TFESI on a patient because he had a prior epidural done 8 months ago by a different doctor that didn't help. I offered the patient the option to pay cash for the injection ($300) and bypass insurance and they agreed.

Jesus, just imagine what kind of world we live in if people couldn't pay cash for their own health care.

 

[epidural man]

Cash pay seems like the best way to go for pain procedures.

If the procedure works well enough, they will pay. If it doesn't, they won't pay again. That seems to solve several conflicts of interest.

 

[Pain Applicant1]

At least with this plan it seems to be okay as long as you adhere to the rules.

"A provider may charge a Medicaid beneficiary, including a Medicaid or FHPlus beneficiary enrolled in a managed care plan, only when both parties have agreed prior to the rendering of the service that the beneficiary is being seen as a private pay patient.
This agreement must be mutual and voluntary. It is suggested that providers keep the beneficiary’s signed consent to be seen as a private pay patient on file."

You are being redirected...

There are so many caveats that I bet it would be impossible to get one correct answer, even if you called them. I also bet that if you and the patient agreed and you collected payment upfront it would be very unlikely that there would be any issue from anyone regarding this.

 

[mid|ine]

What is the threat on the other end? Medicaid kicks you off there panel? Thank you!

 

[Painologist]

At least with this plan it seems to be okay as long as you adhere to the rules.

"A provider may charge a Medicaid beneficiary, including a Medicaid or FHPlus beneficiary enrolled in a managed care plan, only when both parties have agreed prior to the rendering of the service that the beneficiary is being seen as a private pay patient.
This agreement must be mutual and voluntary. It is suggested that providers keep the beneficiary’s signed consent to be seen as a private pay patient on file."

You are being redirected...

There are so many caveats that I bet it would be impossible to get one correct answer, even if you called them. I also bet that if you and the patient agreed and you collected payment upfront it would be very unlikely that there would be any issue from anyone regarding this.

That being said, does anyone have an example "cash pay acknowledgement" contract you have patient's sign in these scenarios?

 

[Cholula]

That being said, does anyone have an example "cash pay acknowledgement" contract you have patient's sign in these scenarios?

I think what you are looking for is an Advanced Beneficiary Notice of Noncoverage. Search online for CMS-R-131 word doc form, then change the insurance carrier to what your patient has.