Billing Medicaid in Third-Party Liability Cases
One assertion we often hear is, “Instead of filing a hospital lien, the hospital should bill these charges to Medicaid.”
However, by statute Medicaid is a “payor of last resort”. If there is some other “third-party resource”, the provider is expected to seek payment from that source rather than from Medicaid.
For instance, the Texas Medicaid Provider Procedures Manual, Vol. 1, 2012 edition, states in pertinent part (all emphasis added):
4.13 Third Party Liability (TPL)
Federal and state laws require the use of Medicaid funds for the payment of most medical services only after all reasonable measures have been made to use a client’s third party resources (TPR) or other insurance.
To the extent allowed by federal law, a health-care service provider must seek reimbursement from available third party insurance that the provider knows about or should know about before billing Texas Medicaid. …
A TPR is a source of payment for medical services other than Medicaid, the client, and non-TPR sources. TPR includes payments from any of the following sources:
• No-fault automobile insurance such as personal injury protection (PIP) and automobile medical insurance
• Liability insurance
• Other liable third parties
In fact, services payable by third-party resources are not Medicaid benefits. The Provider Procedures Manual also states:
1.8 Texas Medicaid Limitations and Exclusions
Medicaid pays for services on behalf of clients to the provider of service according to Texas Medicaid’s limitations and procedures. TMHP does not make Medicaid payments directly to clients.
The following services, supplies, procedures, and expenses are not benefits of Texas Medicaid. This list is not all inclusive.
• Care and treatment related to any condition for which benefits are provided or available under Workers’ Compensation laws [just shown as one example].
• Services that are payable by any health, accident, other insurance coverage, or any private or other governmental benefit system, or any legally liable third party.