Question

You are processing a refill for a specialty medication for a patient who has both Medicare and Medicaid. Which of the following is the correct order of billing?

1) Medicare -> Medicaid -> Manufacturer PAP
2) Medicaid -> Medicare -> Manufacturer PAP
3) Medicaid -> Medicare
4) Medicare -> Medicaid

Answer 1

In processing a refill for a specialty medication for a patient with both Medicare and Medicaid coverage, Medicare is billed first, followed by Medicaid, and finally, the Manufacturer's Patient Assistance Program, if available.

Step-by-step explanation:

When processing a refill for a specialty medication for a patient with both Medicare and Medicaid coverage, the correct order of billing typically adheres to the 'payer of last resort' rules. In most cases, the primary payer is Medicare, and therefore, it should be billed first. Once Medicare has paid its share, Medicaid can be billed for any remaining costs as a secondary payer. This is due to Medicaid often being the payer of last resort. If there is a manufacturer's Patient Assistance Program (PAP) involved, it would generally come into play after both Medicare and Medicaid have been billed. Therefore, the correct sequence would be:

1. Medicare
2. Medicaid
3. Manufacturer PAP

This aligns with practices to ensure that the Medicare benefits are utilized before Medicaid, thus maximizing the resources available to the patient before seeking assistance from a Patient Assistance Program.