Guest guest Posted September 20, 2004 Report Share Posted September 20, 2004 What is the possibility of the pt requesting a Medicaid exemption and deferring back to the original Fee for service plan. I have done this in the past for MA Managed Care that we do not contract with. Sioson wrote: A new question to all...Patient had undergone a heart txp at our facility 15 years ago. Now, at30 years of age, she needs a kidney transplant, borderline dialysis.She resides in the neighboring state where she has an HMO Medicaid. Sheis Medicare ineligible for ESRD - not enough working quarters. She hasbeen on disability, but never had Medicare. At the time of her hearttxp, as per patient's mother, Medicare based on diasbility under one ofthe parents was not pursued because patient was fully insured underdad's EGHP.As per case manager, eval w/ possible kidney transplant was denied dueto non-participating facility and physicians. Negitiation is out of thequestion and I tried to argue for her continuity of care, and stilldenied. I am just waiting for the denial in writing to start theappeals process.Is anyone aware of any law that can relate to continuity of care forthis special case - 2 txps. I just can't believe that the HMO woulddeny her transplant at our center. Is this legal ? Since she isalready established for a long time, I thought the HMO Medicaid would beobligated to pay and will try to negotiate on a fee.Any comments will be appreciated.Thanks- Siosonbegin:vcard n:Sioson;tel;fax:tel;work:x-mozilla-html:FALSEorg:New York Presbyterian Hospital;Renal Transplantversion:2.1email;internet:cap7002@...title:Financial Coordinatoradr;quoted-printable:;;622 West 168th Street=0D=0APH12-1289;New York;NY;10032;fn: Siosonend:vcardBessie Plummer Financial Coordinator/Office Manager Jefferson University HospitalTransplant Program111 S. 11th Street/ Ste 1950Philadelphia, PA 19107fax: __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 20, 2004 Report Share Posted September 20, 2004 that's an option, but straight medicaid will not authorize care outside the residing state. pt lives in NJ and service is in NY. at least with the HMO, we can negotiate on percentage off charges. straight medicaid, my docs do not participate, therefore no pymnt specially out-of-state medicaid.. thanks for the input. Bessie Plummer wrote: What is the possibility of the pt requesting a Medicaid exemption and deferring back to the original Fee for service plan. I have done this in the past for MA Managed Care that we do not contract with. Sioson wrote: A new question to all... Patient had undergone a heart txp at our facility 15 years ago. Now, at 30 years of age, she needs a kidney transplant, borderline dialysis. She resides in the neighboring state where she has an HMO Medicaid. She is Medicare ineligible for ESRD - not enough working quarters. She has been on disability, but never had Medicare. At the time of her heart txp, as per patient's mother, Medicare based on diasbility under one of the parents was not pursued because patient was fully insured under dad's EGHP. As per case manager, eval w/ possible kidney transplant was denied due to non-participating facility and physicians. Negitiation is out of the question and I tried to argue for her continuity of care, and still denied. I am just waiting for the denial in writing to start the appeals process. Is anyone aware of any law that can relate to continuity of care for this special case - 2 txps. I just can't believe that the HMO would deny her transplant at our center. Is this legal ? Since she is already established for a long time, I thought the HMO Medicaid would be obligated to pay and will try to negotiate on a fee. Any comments will be appreciated. Thanks- Sioson begin:vcard n:Sioson; tel;fax: tel;work: x-mozilla-html:FALSE org:New York Presbyterian Hospital;Renal Transplant version:2.1 email;internet:cap7002@... title:Financial Coordinator adr;quoted-printable:;;622 West 168th Street=0D=0APH12-1289;New York;NY;10032; fn: Sioson end:vcard Bessie Plummer Financial Coordinator/Office Manager Jefferson University Hospital Transplant Program 111 S. 11th Street/ Ste 1950 Philadelphia, PA 19107 fax: __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 20, 2004 Report Share Posted September 20, 2004 that's an option, but straight medicaid will not authorize care outside the residing state. pt lives in NJ and service is in NY. at least with the HMO, we can negotiate on percentage off charges. straight medicaid, my docs do not participate, therefore no pymnt specially out-of-state medicaid.. thanks for the input. Bessie Plummer wrote: What is the possibility of the pt requesting a Medicaid exemption and deferring back to the original Fee for service plan. I have done this in the past for MA Managed Care that we do not contract with. Sioson wrote: A new question to all... Patient had undergone a heart txp at our facility 15 years ago. Now, at 30 years of age, she needs a kidney transplant, borderline dialysis. She resides in the neighboring state where she has an HMO Medicaid. She is Medicare ineligible for ESRD - not enough working quarters. She has been on disability, but never had Medicare. At the time of her heart txp, as per patient's mother, Medicare based on diasbility under one of the parents was not pursued because patient was fully insured under dad's EGHP. As per case manager, eval w/ possible kidney transplant was denied due to non-participating facility and physicians. Negitiation is out of the question and I tried to argue for her continuity of care, and still denied. I am just waiting for the denial in writing to start the appeals process. Is anyone aware of any law that can relate to continuity of care for this special case - 2 txps. I just can't believe that the HMO would deny her transplant at our center. Is this legal ? Since she is already established for a long time, I thought the HMO Medicaid would be obligated to pay and will try to negotiate on a fee. Any comments will be appreciated. Thanks- Sioson begin:vcard n:Sioson; tel;fax: tel;work: x-mozilla-html:FALSE org:New York Presbyterian Hospital;Renal Transplant version:2.1 email;internet:cap7002@... title:Financial Coordinator adr;quoted-printable:;;622 West 168th Street=0D=0APH12-1289;New York;NY;10032; fn: Sioson end:vcard Bessie Plummer Financial Coordinator/Office Manager Jefferson University Hospital Transplant Program 111 S. 11th Street/ Ste 1950 Philadelphia, PA 19107 fax: __________________________________________________ Quote Link to comment Share on other sites More sharing options...
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