Medicaid Payer Case Study

Per our conversation: When the provider bills an amount, we don’t always pay that billed charges. Providers tend not to change the amount they are bill with different insurances. Amerigroup pays 100% of the Medicaid Fee Schedule. The claims that your referencing below paid code 20160RT at $66.09 per the Medicaid Fee Schedule. However, code J7324 denied for authorization. I understand that authorization was waived for April, I will have this claims reprocessed. Once the auth. wavier is put in place, code J7324 pays $223.39 of the Medicaid Fee Schedule. This bring the amount of the claim to $289.48 of the $473.00 the provider is billing.

A Spanish-speaking member of Kentucky medicaid called in to the call center where I working in Louisville, KY. She quickly started to talk, she sounded very afraid. she was crying and begging me not to cancel her childrens medicaid. Once there was a pause I quickly stepped in and comforted her by telling her that I am here to help her the best way I can. She was acting this way because she receive a letter from the state and assumed they were going to cancel her kids medicaid because she missed an appointment, she didn't understand the letter very well and couldn't translate it for me but she did mention the name of our company was on the letter. I had an idea of what is what about but just to be 100% I asked the customer if it was not too

Initial diagnosis of Streptococcal pharyngitis is determined by a point system awarding 1 point for each of the following; temperature greater than 38 C, absence of cough, tender anterior cervical lymph nodes, tonsillar swelling, age younger than 15, subtracting a point for age older than 45. If these symptoms are met, a rapid strep test will be performed before antibiotics are given, a precaution taken to prevent super-bugs from developing.

Bill Haslam, the Tennessee state governor, announced that the state of Tennessee would accept the Medicaid expansion offer. The Medicaid expansion expands Medicaid eligibility to the region’s underserved populations living near or below the poverty line. The Medicaid expansion offer looked to be a major win for the state; however, others disagreed with this idea. Some of Tennessee’s lawmakers decided to deny the federal government’s Medicaid offer, even though many others wanted the offer to be accepted. The deal’s breakdown might be the result of “squabbling along party lines” which is a common theme at all levels of government. Although the deal was denied, it is still possible that the bill could still be passed with the help of the governor. The likelihood of Tennessee reviving its Medicaid expansion is a difficult one considering the state would have to fight. The Medicaid expansion could offer the state low-income citizens medical insurance, the state would come out of the deal with a net financial gain, and the state hospitals would come out on top.

The Affordable Care Act includes a requirement that all citizens must have some level of health coverage. The primary method through which the mandate is attempting to create 100% coverage in health care is by instilling fear into the minds of hardworking citizens as those who ignore the rule will have to pay a hefty fine. This mandate, unconstitutional according to the law, will deteriorate the quality of health care, hamper economic growth and cause spikes in insurance premiums. The hope of universal health care may or may not arise under the mandate but new dilemmas and hardships on U.S. citizens will undoubtedly surface.

Texas ranks number one with the highest uninsured rate in the nation, accounting for nearly 6 million people (1). The federal government has nearly $100 billion for Medicaid expansion, out of which $15 billion is needed for expansion in Texas (1). Opting out of Medicaid expansion has left 1.5 million eligible Texans without health insurance (2). Consequently, a 300 percent increase in costs for primary care services, being provided in the emergency department, has been observed (1). Similarly, most hospitals are facing nearly $3-5 billion in losses due to uncompensated care (1).

In the state of Texas Medicaid is funded by state and federal programs. Those eligible to receive Medicare benefit is the low income individuals, families, children, pregnant women, elderly and individuals who suffer with disabilities (Hegar). The Texas Health and Human Service commission (HHSC) distributes the Medicaid (Hegar). Those receiving Medicaid benefits in the fiscal year of 2010 were found to be 55 percent female and 77 percent under the age of 21 (Hegar). Children accounted for 66 percent of all Texas Medicaid recipients in that year; however, 32 percent of those children actually received health care (Hegar).

The Affordable Care Act (ACA) was signed into law by President Barack Obama on March 23, 2010, and on June 28, 2012 the Supreme Court decided to uphold the law.¹ Some of the most notable features that the ACA will provide for individuals are access to healthcare for everyone, new consumer protections such as pre-existing condition coverage, free preventative care, protection against healthcare fraud, small business tax credits, as well as many other features.¹

Medicaid expansion is seen as a huge problem in this case it takes place among the 50 states. The environment includes the 50 states such as California, Texas, New York and New Jersey. Medicaid expansion offers financial protection. It also addresses the uncompensated care problem which involves paying and reimbursement for service rendered. Medicaid expansion also provides customers access to affordable coverage, as well as customers taking up that cover, which is a moral duty of the government. Medicaid also supports politically powerful interest groups who support expansion. The expansion of Medicaid helps rural hospitals stay afloat in states like Colorado, which added 400,000 people to the health insurance program under

Following the death of a Medicaid recipient, the program not only can but must attempt to recover costs from the estate of the deceased. Medicaid's official site says:

Effective May 30, 2018, the Virginia General Assembly approved Medicaid Expansion as a part of the 2019-2020 budgets. Virginia’s Governor Northam signed this approval into law on June 7, 2018, and as a result, approximately 400,000 low-income adults now qualify for health insurance (Norris, 2018). The General Assembly vote ended a “long-running partisan stalemate” with some Republicans joining the Democrats in support (The Associated Press, 2018). The Kaiser Family Foundation reports that Virginia is the 33rd state to approve the Medicaid Expansion (The Associated Press, 2018).

With the implementation of the ACA, many states have expanded their Medicaid programs to include a larger population of low income individuals and families that were not able to obtain health insurance prior to the law. Some of the issues that state legislators struggle with are the overall cost of providing services for the additional recipients, staying within budget, determining an adequate approach of offering quality care, and providing adequate coverage for each recipient. Even though the cost of Medicaid expansion within each state has increased the budget for the program, new appraisals has shown that Medicaid programs spend less per enrollee than commercial health insurance and much of the increase in Medicaid expenses originate from the increase in enrollment in the programs (Coughlin, Long, Clemens-Cope, & Resnick, 2013).

As Congress considers potential options to reform Medicaid, it is important to keep in mind patient access to prescription drugs and other healthcare services. Retail community pharmacies believe that Medicaid prescription drug benefit reform efforts should be focused on maintaining a Medicaid prescription drug benefit, maintaining patient access to adequate provider networks, fair and appropriate cost-based provider payments, and facilitating patient access to pharmacist-provided health care services.

The Affordable Care Act (ACA) highlighted the importance Medicaid played in insuring every American receive healthcare coverage. (42 U.S.C., 2010) Medicaid provides health benefits to over 71 million across the country. While involvement is optional, all 50 states participate in the program and requirements differ across the nation. The flexibility given to each state has allowed them to make their own decisions to work towards improvements that they believe would best benefit their region (Feldstein, 2015, p. 125-126).

Medicaid is both an extremely important and costly government program. The program provides medical care for those who cannot afford it and also for the elderly and the disabled. Over 69 million people were provided medical assistance through Medicaid in the fiscal year of 2011 (Herz). Medical attention is very expensive but is also something that every human being needs. Some people are individually wealthy enough to afford medical insurance. Most people are provided medical insurance through their employer. So what are those people who are unemployed and not independently wealthy supposed to do? If you have no job you have no insurance through your employer