Possible Changes to Ohio Medicare Medicaid Crossover Claims

While the specific details and statutory language for the budget will not be available for another week or so, the OSMA has identified two Medicaid payment reforms that could impact certain physician practices.

The first provision indicates that, effective July 1, 2011, if a Medicaid rate for a particular CPT code exceeds the Medicare rate for that code, the Medicaid rate will be reduced to equal the Medicare rate. The OSMA has determined that there are a small number of codes where this in fact occurs and we would be interested in knowing whether this proposed change will have a significant impact on your practice.

The second proposed change deals with “crossover payments,” where patients are dually eligible for Medicare coverage and Medicaid coverage. Under current law, Medicaid is the secondary payer for dual eligibles and picks up any cost-sharing obligation the patient might have under Medicare coverage policies.

The governor’s budget will require ODJFS to compare the payment Medicare makes under Part B to the payment Medicaid would have paid if Medicaid were the primary payer. If the Medicare payment is equal to or exceeds the payment Medicaid would have made, then the physician would be considered paid in full and no further payment will be made.

This provision could negatively impact those practices that have a large number of patients that are Medicare and Medicaid eligible.

Source OSMA