Crossover Billing Begins For N.Y. Dual Eligibles

Albany, N.Y.

In December, the New York State Department of Health implemented a new procedure for billing Medicaid for Medicare co-insurance and deductible amounts for dual eligibles, or those eligible for both Medicaid and Medicare.

The procedure follows state statutory changes enacted July 1, which reduced reimbursement to 20 percent of the 20 percent co-insurance cost, essentially representing a 16 percent cut, according to the New York Medical Equipment Providers association. For example, if a DME product costs $100, Medicare will pay $80, and the state’s Medicaid program will only reimburse $4 of the remaining $20 co-insurance, leaving $16 for the provider to absorb.

Excluding pharmacy drug claims, according to NYMEP, the procedure is effective retroactively for dual-eligible claims submitted with dates of service on or after July 1, 2003, the beginning of the state’s fiscal year.

“We’re still … asking for a repeal of this law as we go into the next [legislative] session,” said Jackie Negri, NYMEP executive director.

She added that not only could such drastic cuts limit beneficiary access, the new billing procedures are “extremely complex,” especially for HME providers. “Even though this affects physicians [and other providers], HME is the most complex because there are so many [pieces of] equipment and associated codes,” she said, explaining that for dual-eligible items, providers must now submit separate claims for the Medicare deductible amount and the co-insurance amount.

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