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If the MD is not signed up with Wisconsin medicaid (and the state rejects saying they're not signed up), may the patient pay cash for the Rx? Yes or no? Does controlled vs non-controlled matter?
Wisconsin Medicaid Question
- Thread starter Charcoales
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The most common reasons for this occuring is a Rx from a resident or MD not sending in the renewal information. You call the hospital and get the attending MD to sign off on the prescription if it is a resident. You can also call the office.
I have also seen this on out of state physicians and rarely some dentists.
I believe they can pay cash if the prescribers isn't covered. However, this is a very rare situation.
I have also seen this on out of state physicians and rarely some dentists.
I believe they can pay cash if the prescribers isn't covered. However, this is a very rare situation.
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Thanks for the reply.
This was from an independent Dentist. We asked their office if there were any other providers with Medicaid coverage but no luck. It was for an antibiotic.
There's no way for the pt to have known beforehand. In this situation, I wouldn't object to the pt paying out of pocket. I'd still check PMP and things of course.
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Cannot pay cash as they will lose medicaid
owlegrad
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Ridiculous, I don't believe this for a second. Do you have anything to support this claim? What about drinking Starbucks or owning an iPhone? Perhaps driving a nice car also gets you kicked off medicaid?
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No, this really is a thing in some states. It's not made up. I don't know about WI, but I wouldn't be surprised if they had that rule.
Pharmacies and healthcare providers that provide pharmacy services can also lose their contracts with some state Medicaid programs when allowing patients to pay cash for unauthorized dispenses (including provider not contracted/signed up).
Yeah WI is one of those states where the patient can lose Medicaid if they pay cash and the pharmacy/provider can lose their contract if they let the patient pay cash for unauthorized dispenses.
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So it's okay for the patient to go to this dentist who's not signed up for Medicaid but they can't fill a prescription from him/her? I can't wrap my head around this concept at all, lol. So what does the patient do, just not take the antibiotic?
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I briefly looked up WI Medicaid rules, and it appears that is correct. In that situation, the pharmacy (contracted with Medicaid) should not allow the patient to pay cash (mostly due to risk of the pharmacy losing their Medicaid contract), but instead contact the prescriber to see if they have another prescriber contracted with Medicaid who would allow their name on the script. Perhaps their regular dentist, or their regular PCP.
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Let's just say the patient was irate when we told them this (I couldn't believe it myself but the senior tech said they could lose their medicaid... Wasn't sure enough to challenge them)...
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I generally let them know that not only could they lose their Medicaid, but we could lose our ability to provide care for all Medicaid patients statewide. They usually agree and let us pursue another provider for the script. Sometimes it's a total pain though -- there have been some rough situations (post surgical pain specifically, with CIIs signed off on by by a resident...
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Of course it varies by state. I have seen people have to sign a waiver for Texas Medicaid if they choose to pay cash for a prescription when the system detects a Texas Medicaid insurance profile. I guess that is to "protect" the pharmacy too.
And in California, technically a "covered" drug under fee-for-service Medi-Cal is anything that COULD be covered if a successful treatment authorization request is done, even if the drug is not on the contract drug list, so providers "cannot deny services" to covered beneficiaries if "if the service requires the provider to obtain authorization." (This is where we try to convince the prescriber to prescribe something on the contract drug list.) Supposedly this is pursuant to CCR and/or W&I code. I suppose cashing out Rx can be considered a "denial" of services to be billed to Medicaid, but then you run into the issue of people getting pissed off, as shown above, when you say you have to follow the PA process.
Even some of the managed care plans in CA state that Rx requiring prior auth "should not" be cashed out without first following the PA process so that technically places an additional burden on a pharmacy where you have providers that do not even accept Medi-Cal at all (but why are these Medi-Cal recipients going to these providers in the first place...?) and won't change the therapy to what is covered or do any PA for a quantity limit (frequently seen with short-acting opioids as all of the managed care plans have some combination of day-supply, dispensing frequency or total quantity limits per dispensing)
And in California, technically a "covered" drug under fee-for-service Medi-Cal is anything that COULD be covered if a successful treatment authorization request is done, even if the drug is not on the contract drug list, so providers "cannot deny services" to covered beneficiaries if "if the service requires the provider to obtain authorization." (This is where we try to convince the prescriber to prescribe something on the contract drug list.) Supposedly this is pursuant to CCR and/or W&I code. I suppose cashing out Rx can be considered a "denial" of services to be billed to Medicaid, but then you run into the issue of people getting pissed off, as shown above, when you say you have to follow the PA process.
Even some of the managed care plans in CA state that Rx requiring prior auth "should not" be cashed out without first following the PA process so that technically places an additional burden on a pharmacy where you have providers that do not even accept Medi-Cal at all (but why are these Medi-Cal recipients going to these providers in the first place...?) and won't change the therapy to what is covered or do any PA for a quantity limit (frequently seen with short-acting opioids as all of the managed care plans have some combination of day-supply, dispensing frequency or total quantity limits per dispensing)
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