Balance Billing
Date: 08/30/24
Member Billing Guidelines for Indiana Medicaid Members:
Providers who provide care for Indiana Medicaid members must adhere to specific guidelines that protect members from inappropriate billing practices. Below is a detailed explanation of these guidelines to ensure clarity and compliance:
No Balance Billing: Providers must not charge members amounts exceeding what Medicaid allows or for services that Medicaid does not cover. This rule prevents members from being billed for the difference between the provider’s charge and the Medicaid payment.
No Standard Waivers: Providers cannot use standard waivers to make members responsible for a bill.
No Refusal of Service: Providers cannot refuse to see a member because of an unpaid bill for services rendered while the member is covered by the Indiana Health Coverage Programs (IHCP). This ensures that members continue to receive necessary medical care without disruption.
No Billing for Medical Records: Members cannot be billed for obtaining their medical records. Access to personal health information is a right, and providers must comply without imposing fees.
No Charges for Missed Appointments: Providers cannot impose charges on members for missed appointments. This policy recognizes that members may face various barriers that prevent them from attending scheduled appointments and ensures they are not penalized financially.
In certain cases, providers may charge IHCP members for services not covered by the IHCP. For example, services not covered by the IHCP can be billed to the member if the following conditions are met. Providers must obtain and keep a signed statement from the member, which confirms their responsibility for specific services.
Requirements for Billing Non-Covered Services
To bill members for services not covered by IHCP, providers must follow these steps:
Obtain Member Consent: Providers must secure a signed statement from the member accepting fiscal responsibility for specific services. This statement should clearly outline the services being billed.
Timing of Consent: The consent form must be signed by the member before receiving the services. This ensures that members are fully aware of their financial obligations ahead of time.
Documentation: The signed statement must be retained in the patient’s medical record. The document must not contain any conditional language. This documentation serves as proof of the members’ agreement to pay for the services.
Recurrent Services: For recurring services not covered by IHCP, a new waiver must be signed each time the service is provided. For example, if a member has exhausted their yearly limit for chiropractic adjustments, the provider must obtain a waiver specific to each additional adjustment.
For more information, please refer to the Provider Enrollment Module of the IHCP Provider Reference Modules.
Actions for Inappropriate Billing
If a member reports inappropriate billing to MHS, the following steps are taken:
Notification: MHS will notify the provider of the member’s rights and the violation of billing rules.
Reporting to OMPP (Office of Medicaid Policy and Planning): If the provider continues to bill the member inappropriately, a report will be filed with the Office of Medicaid Policy and Planning (OMPP). OMPP has the authority to terminate a provider’s participation in the IHCP for persistent non-compliance with billing regulations.
The No Suprises Act:
For more comprehensive protection against unexpected medical bills, members and providers should be aware of the federal No Surprises Act, which went into effect on January 1, 2022. This law helps protect individuals from surprise medical bills for services received at in-network facilities but provided by out-of-network providers. For more information, please visit The No Surprises Act.
By adhering to these detailed guidelines, providers can ensure they remain compliant with state and federal laws, protecting both themselves and their patients from financial disputes and ensuring a transparent healthcare experience.
You may contact your MHS Provider Engagement Administrator or Customer Service Advocate at 1-877-647-4848 with any questions or concerns about this communication.
Thank you for being our partner in care.