Question: I have a case where the hospital has a claim that needs to be submitted to Medicaid for payment. However, since the hospital knows that there is a liable third party, they are refusing to submit the claim to Medicaid. How can I force the hospital billing office to submit the claim for payment? – FL Attorney
Answer: In this instance, the provider has the right to go either way, so there is no real avenue to “force” a provider to bill Medicaid for services. Under Medicaid’s provider agreement, the hospital has the right to bill all other insurers first, with Medicaid being the final payer. On the other hand, Medicaid has the right to subrogate for payments made when a third party is responsible.
Medicaid as Final Payer – Why the Provider can bill liable insurer: FL Statute 409.907(3)(f) – Medicaid Provider Agreement (3) The provider agreement developed by the agency, in addition to the requirements specified in subsections (1) and (2), shall require the provider to: (f) Bill other insurers and third parties, including the Medicare program, before billing the Medicaid program, if the recipient is eligible for payment for health care or related services from another insurer or person, and comply with all other state and federal requirements in this regard.
Medicaid Right of Recovery – Why the Provider can bill Medicaid even if there is a liable third party: FL Statute 409.910(4)(a)(b) – Responsibility for payments on behalf of Medicaid-eligible persons when other parties are liable.(4) After the agency has provided medical assistance under the Medicaid program, it shall seek recovery of reimbursement from third-party benefits to the limit of legal liability and for the full amount of third-party benefits, but not in excess of the amount of medical assistance paid by Medicaid, as to: (a) Claims for which the agency has a waiver pursuant to federal law; or (b) Situations in which the agency learns of the existence of a liable third party or in which third-party benefits are discovered or become available after medical assistance has been provided by Medicaid.
So if the provider wants to receive payment from the third party insurer, they have the right to do so, though the payment may not be received as quickly. If Medicaid is billed, it is still the responsibility of the third party to reimburse Medicaid for payments made on their behalf. To answer your question, there is no way to force the submission of a claim, however, you can make the provider aware that they may receive payment from Medicaid sooner, if the case has yet to settle with the liable party. Hope this helps!