08/17/2023

Michigan Medical Billing Updates

Michigan's Surprise Medical Billing Law

The Michigan Act typically applies to three types of treatment rendered by nonparticipating providers:

1. Treatment of all emergency patients
2. Services to non-emergency patients in participating hospitals where the patient does not have the opportunity to choose a participating provider (or the patient has not been provided with prior disclosure); and
3. Treatment of patients admitted to a hospital within 72 hours after receiving treatment in that hospital's emergency department.

Below are some links with more detailed information.

Insti_Billing_Tip_Hospital_Billing_Beneficiary_new_05152017.pdf (michigan.gov)

www.mondaq.com/unitedstates/healthcare/1155474/surprise-new-laws-impact-patient-billing

Michigan Medicaid

Are you confused on where to go to get up to date information, or how to find other resources for Michigan Medicaid?  Below are some resources that are available.  Be sure to also sign up for their email updates.

Can I bill a Medicaid beneficiary? According to MI Medicaid policy you can in certain instances. please see the excerpt from the Michigan Medicaid Policy Manual which can also be found at :                                                                          

https://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf    

General information section for Providers, Section 10.1 Billing Beneficiaries:

Providers cannot bill beneficiaries for services except in the following situations:

* A Medicaid copayment is required. (Refer to the Beneficiary Copayment Requirements subsection of this chapter for additional information about copayments.)

* A monthly patient-pay amount for inpatient hospital or nursing facility services. The local MDHHS office determines the patient-pay amount. Noncovered services can be purchased by offsetting the nursing facility beneficiary's patient-pay amount. (Refer to the Nursing Facility Chapter for additional information.)

* For nursing facility (NF), state-owned and -operated facilities or CMHSP-operated facilities determine a financial liability or ability-to-pay amount separate from the MDHHS patient-pay amount. The state-owned and -operated facilities or CMHSP-operated facilities liability may be an individual, spouse, or parental responsibility. This responsibility is determined at initiation of services and is reviewed periodically. The beneficiary or his authorized representative is responsible for the state-owned and -operated facilities or CMHSP ability-to-pay amount, even if the patient-pay amount is greater.

* The provider has been notified by MDHHS that the beneficiary has an obligation to pay for part of, or all of, a service because services were applied to the beneficiary's Medicaid deductible amount.

Providers cannot bill beneficiaries for services except in the following situations:

* If the beneficiary is enrolled in a MHP and the health plan did not authorize a service, and the beneficiary had prior knowledge that he was liable for the service. (It is the provider’s responsibility to determine eligibility/enrollment status of each beneficiary at the time of treatment and to obtain the appropriate authorization for payment. Failure of the provider to obtain authorization does not create a payment liability for the beneficiary.)

* Medicaid does not cover the service. If the beneficiary requests a service not covered by Medicaid, the provider may charge the beneficiary for the service if the beneficiary is told prior to rendering the service that it is not covered by Medicaid. If the beneficiary is not informed of Medicaid noncoverage until after the services have been rendered, the provider cannot bill the beneficiary.

* Beneficiaries may be billed the amount other insurance paid to the policyholder if the beneficiary is the policyholder.

* The beneficiary is the policyholder of the other insurance, and the beneficiary did not follow the rules of the other insurance (e.g., utilizing network providers).

* The provider chooses not to accept the beneficiary as a Medicaid beneficiary and the beneficiary had prior knowledge of the situation. The beneficiary is responsible for payment.

It is recommended that providers obtain the beneficiary's written acknowledgement of payment responsibility prior to rendering any nonauthorized or noncovered service the beneficiary elects to receive. Some services are rendered over a period of time (e.g., maternity care). Since Medicaid does not normally cover services when a beneficiary is not eligible for Medicaid, the provider is encouraged to advise the beneficiary prior to the onset of services that the beneficiary is responsible for any services rendered during any periods of ineligibility. Exceptions to this policy are services/equipment (e.g., root canal therapy, dentures, custom-fabricated seating systems) that began, but were not completed, during a period of eligibility. (Refer to the provider-specific chapters of this manual for additional information regarding exceptions.)

When a provider accepts a patient as a Medicaid beneficiary, the beneficiary cannot be billed for:

* Medicaid-covered services. Providers must inform the beneficiary before the service is provided if Medicaid does not cover the service.

* Medicaid-covered services for which the provider has been denied payment because of improper billing, failure to obtain PA, or the claim is over one year old and has never been billed to Medicaid, etc.

* The difference between the provider’s charge and the Medicaid payment for a service.  Missed appointments.

* Copying of medical records for the purpose of supplying them to another health care provider.

If a provider is not enrolled in Medicaid, they do not have to follow Medicaid guidelines about reimbursement, even if the beneficiary has Medicare as primary.

Providers cannot bill beneficiaries for services except in the following situations:

If a Medicaid-only beneficiary understands that a provider is not accepting him as a Medicaid patient and asks to be private pay, the provider may charge the beneficiary its usual and customary charges for services rendered. The beneficiary must be advised prior to services being rendered that his mihealth card is not accepted and that he is responsible for payment. It is recommended that the provider obtain the beneficiary's acknowledgement of payment responsibility in writing for the specific services to be provided.

When billing Medicaid Beneficiaries, it is suggested to always have them sign a waiver.  This is YOUR proof that the patient was notified and agreed to the charges.  Below is a copy of the waiver that our office uses.  The waiver is used per date of service, it does not cover more than one date. It is also suggested to put the actual service down, this will also help if you are ever called on to provide proof that you informed the patient PRIOR to the visit.

Resources: Michigan Medicaid Policy Manual Version Date 07/01/2023

Brought to you by your West Chapter Co-Chairs:

Analiza Mejia-Urias, CPB, CPC, CH-CBS, CH-CS 

Luisa Ortiz, BSBM, MBA-HC