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3/12/2007 12:00:00 AM

Reimbursement Change Implemented for Medicaid and Commercial Insurance

Subject: Reimb. Change Implemented for Medicaid & Commercial Insurance


 For further information, contact: Deb Williams & Joanne Genovese

M e m o r a n d u m

TO:                  PCG Contact Person

Clinic Directors

                        Finance Directors


FROM:            Deb Williams, Vice President, Reimbursement & Regulatory Compliance

                        Joanne Genovese, Vice President, Regulatory Affairs & Policy Development

DATE:              March 12, 2007

RE:                  Reimbursement Change Implemented For Medicaid and Commercial Insurance

Please be aware that an edit has been made to the eMedNY system resulting in a change to the way providers are reimbursed for services to consumers who have Commercial Insurance (CI) and Medicaid. 

We do not believe that this change applies to our Article 28 and 16 clinics and have had several discussions with the Department of Health (DOH) expressing this.  Due to our concerns, DOH met internally on Friday to discuss and review the basis for this edit.  At this time, DOH will continue researching the issue to determine how CI should be reimbursed. 

We will continue working with DOH to resolve this issue. Unfortunately, until we can resolve this, you may see a change in your reimbursement for claims with CI and Medicaid.  The payment change is as follows:

Rather than being paid up to the clinic rate, the new reimbursement holds providers to the total of the amount paid by the CI plus the lower of the Patient Responsibility (PR) portion (co-pays, co-insurances, deductibles) or the balance between the CI paid amount and the Medicaid rate.  For example, for a provider with a $50 clinic rate, if the CI pays $25 and the PR portion is $10, the provider would be paid the $25 from the CI and $10 from Medicaid for a total of $35, rather than being paid $25 from the CI and $25 from Medicaid to provide a total payment equal to their clinic rate of $50.

The January 2007 Medicaid Update discusses this change and notes an implementation date of January 18, 2007.  Therefore, any claims billed as of 1/18/07 for consumers with CI and Medicaid will be paid using the new reimbursement system and it is likely that you will be paid less than your clinic rate for these claims. 

We will keep you apprised of any developments with this issue.  If you have any questions, please feel free to contact either of us at (518) 436-0178.

cc:  Executive Directors

*  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *  *

Deb Williams

VP, Reimbursement & Regulatory Complianc

[email protected]

Joanne Genovese

Regulatory Affairs & Policy Development

[email protected]

Cerebral Palsy Associations of NYS

90 State Street, Suite 929

Albany, New York   12207

(518) 436-0178

Fax:  (518) 436-8619

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