Just like Lucy pulling the football away from Charlie Brown, Medicaid loves to play games with the pediatrician.
For the uninformed, a primer: Medicaid is the government's "safety net" insurance program for the poor. Many children are covered by Medicaid (in fact, here in Mississippi, about 3 out of 4 are). The federal government provides much of the funding, with the rest coming from each state, and each state also administers the program. Each state provides benefits as it sees fit--within certain broad federal guidelines--and can also set provider reimbursement in a similar way.
Medicaid represents government at its best and worst. The concept is wonderful, and enables patients to receive care at any willing provider. But the bureaucracy can be inscrutable, bizarre, and sometimes downright moronic, bordering on abusive and arrogant.
At the end of last week my billing manager was reviewing our past few statements from Medicaid, and she found that most of our newborn nursery visits were denied without payment. Late last year Medicaid started requiring prior authorization on many inpatient hospital stays. But babies born eligible for Medicaid don't receive their official Medicaid numbers until 4-8 weeks old.
You can't give a patient a "prior authorization" before they are born, and you also can't give them a P.A. before they have an ID number! The customer service rep agreed, and brought in her supervisor, who told us the grim news: a computer glitch was unexpectedly and incorrectly kicking out these newborn visits. Payment would be forthcoming when the problem was fixed--but that could take weeks to months.
I don't have a problem with providing charity care, as long as I determine the when and how. But I draw the line at systemically providing care for free, particularly when a payor tries to make it so. I can't pay my overhead on goodwill.
And so I am boycotting Medicaid babies until the problem is fixed. No more nursery coverage, unless I absolutely must (e.g., hospital call). I'll see them as soon as they are discharged, for an office follow-up visit. No payment, no care. Or, as others have said, "no margin, no mission."
This is not ideal care. In fact, some might even call it dumping on my colleagues, who will now see "my" babies on "their" nursery rounds. Of course, they have the option to do the same as me, in which case we all dump on each other, and it all evens out. They also have the option to suck it up and continue to provide free care, in which case you may call them "patsy," "sucker," or "loser."
Perhaps I'm deluding myself, but I like to think my profession entails doing some good in this world. I make sure kids stay healthy, or get healthy. This is not about "playing games" or pushing paper, this is about real-world results and making a difference. Compare and contrast with those who seem to erect barriers to said goals.
I'm not accusing Medicaid's bureaucracy of purposefully creating these computerized denials. But I think their response will be most telling, as to how quickly they fix the problem. And trying to deny proper due payment to providers for services rendered--especially contracted services delivered to poor babies--is most certainly "playing games."