Stop me from committing health care fraud. (tongue-in-cheek)
July 16, 2014 2:58 PM   Subscribe

Yeah, I have no intention of committing health care fraud, but I am a bit uncertain on whether I should do this or not (request reimbursement from two insurance companies). More under the fold.

So, to make a complicated situation short and easy to understand, I moved from the west coast to the east coast. I was under the respective west coast state's MedicAid program; now, I'm under the east coast state's MedicAid program.

The west coast state's MedicAid program was a bit vague on whether or not they would reimburse out-of-state costs, but was clear they would reimburse for emergencies. My two medical cases were edge emergencies/urgent/serious, so I submitted the reimbursement forms and the needed proof. The west coast's MedicAid program responded via mail and asked for more proof/more details, such as medical justification, so I gathered the needed information.

While I did that, I did a bit of research on the east coast's state and its' reimbursement policies. As time is running out for the deadline to apply a reimbursement form, along with the needed evidence, I also filled that form out. I've gathered everything I need for the two programs, for reimbursement, but took pause before mailing the two thick envelopes out.

I'm afraid that if I submit reimbursement requests for both MedicAid programs at the same time, this will be considered fraud. The issue is that the east coast MedicAid program has a faster timeline, vs. the west coast state, but I'd like to make sure I have a backup due to the time constraints. Would it be a good idea to submit both simultaneously? What happens if both reimburses me (as in, I get two checks)?

posted by dubious_dude to Law & Government (8 answers total)
I don't think it was crazy to tackle both at once. It is hard to imagine you are eligible for both plans at the same time, and if you somehow are, one will be primary and the other secondary. If both pay as primary, you'd just have to call and straighten out who gets their money back (they'd figure it out on their own soon enough anyway).
posted by ThePinkSuperhero at 3:08 PM on July 16, 2014

To be clear, if you know you are no longer eligible for west coast benefits because you moved, you should not file. If it's unclear, though, file with both and work out eligibility later; you wouldn't want to miss filing deadlines.
posted by ThePinkSuperhero at 3:10 PM on July 16, 2014

Yeah, I've sent out the additional information the west coast MedicAid agency requested today, but the letter they sent mentioned 120 days or so to process everything, and it's not even guaranteed I'll get approved for reimbursement, which is why I want to also apply for the east coast reimbursement, as that's likely to be approved.

I know it's a bit confusing... but bottom line, if I send an reimbursement request to the east coast MedicAid agency while waiting for an answer from the west coast MedicAid agency, that's not insurance fraud and won't get me into any trouble? If I get a refund check from both agencies, what would the best path of course be?
posted by dubious_dude at 3:29 PM on July 16, 2014

I think as long as you are being honest about your residency and all the rest, you are not commuting fraud. Do not file claiming to be living in two different places. I personally highly doubt the west coast program is going to pay if you no longer live there, are you sure you are still eligible after moving? I'm assuming you received care in the EastCoast state after moving. I have never seen a patient with active Medicaid coverage in two states. You are covered where you live.
posted by ThePinkSuperhero at 4:00 PM on July 16, 2014

I think it is only fraud if you keep both checks. If you get both checks and then call and say "Whoops! I was not sure which agency would cover me and there was a filing deadline, so I filed both and now I have two checks. Er, um, what do I do now?" then you should be perfectly A-Okay.

You should only have a problem if you stick both of them in the bank, say nothing to either Medicaid agency and try to keep the profits. So you should be fine mailing in both sets of paperwork on the assumption that one of them will deny it as not covered and you are not clear which one that is.

(I used to work for an insurance company, fwiw.)
posted by Michele in California at 4:52 PM on July 16, 2014 [2 favorites]

I will add that if it gets ugly, this AskMe question is potentially evidence that you had no intent to commit fraud. You have a written public record that you were just trying to make sure you got reimbursed and were not sure which agency would cover you. You would just need to prove that you were the person who posted this Ask.
posted by Michele in California at 5:01 PM on July 16, 2014

I don't know if your assumption that one or both Medicaid plans will reimburse you, even for legitimate, covered medical expenses, is correct. My experience is limited to a couple of state Medicaid plans, and it's on the provider side rather than as a member. To my knowledge, state Medicaid plans will only make payment directly to contracting providers, and will not reimburse or send payment to the member.

Do you also have Medicare, and are you perhaps asking about Medicare? Medicare will reimburse patients for services received from non-contracting providers, and it may be possible to be simultaneously enrolled in two different Medicare Advantage plans. I just haven't heard of Medicaid sending reimbursement checks to members.

If you would like to MeMail me the identity of the plans, I may be better able to help answer your question.

By the way, the government has a program to check for people enrolled in more than one state's Medicaid plan, as it isn't supposed to happen. Here's a Forbes article published just today, focusing on the "Medicaid Interstate Match" program.
posted by Snerd at 5:52 PM on July 16, 2014

Snerd, here's an example of a MedicAid agency offering reimbursement to members.
posted by dubious_dude at 8:13 PM on July 16, 2014

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