Medicaid Reimbursement for Physician Services

Medicaid reimburses for services rendered by licensed, Medicaid-participating doctors of medicine or osteopathic medicine. The services can be rendered in the physician’s office, the patient’s home, a hospital, a nursing facility or other approved places of services as necessary to treat a particular injury, illness, or disease.

LIMITATIONS:

Medicaid reimbursement for physician services is limited to:

• One physician-recipient contact per provider specialty, per day (except for emergencies);

• One long-term care facility service per physician, per month, per recipient (except for emergencies);

• One physician consultation per 365 days, per physician of any specialty, per recipient (for non-hospitalized Medicaid recipients);

• Ten prenatal visits for low-risk pregnancy, fourteen visits for high-risk pregnancy, and two postpartum visits per pregnancy; and

• One new patient evaluation and management service per physician specialty, every three years, if no services were rendered by the physician to the recipient during the prior three years. Subsequent encounters must be reimbursed as established patient evaluation and management services.

Medicaid does not reimburse cosmetic surgery, experimental procedures and eye exams unless related to reported vision problems, illness, disease or injury.

Elective surgery performed within the inpatient hospital setting must be medically necessary and prior authorized, except for recipients under 21 who have been screened in the Child Health Check-Up (formerly known as Early and Periodic Screening, Diagnosis and Treatment [EPSDT]) program within 12 months prior to the date of surgery.

Medicaid does not reimburse abortions except for one of the following reasons:

• The woman suffers from a physical disorder, physical injury or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself that would place the woman in danger of death unless an abortion is performed.

• The pregnancy is the result of incest.

• The pregnancy is the result of rape.

EXCEPTIONS:

The provider may request authorization for reimbursement for services in excess of the service limitations.

ELIGIBILITY:

Medicaid reimburses for physician services for all Medicaid recipients. Recipients whose eligibility is determined through the Presumptively Eligible Pregnant Women program are not eligible for services associated with labor, delivery, postpartum, and inpatient hospitalization. The Department of Children and Families must complete an eligibility determination and find
the recipient eligible under another coverage group before the recipient is eligible for these services.

REIMBURSEMENT:

Medicaid reimbursement for physician services is the maximum Medicaid fee or the provider’s customary fee, whichever is lower.

An exception is certain obstetrical and neonatal services provided in Regional Perinatal Intensive Care Centers (RPICCs), whose payment is based on a Diagnosis Related Group (DRG). DRG payments are prospective and based on average patient lengths of stay in a hospital.

There is a $2 recipient copayment for physician services, per provider, per day, unless the recipient is exempt.