Problem of Medicaid Provider Status vs QMB Reimbursement

I have been reimbursed at my private practice as PMHNP as a Medicare/Medicaid QMB (Qualified Medicare Beneficiary) provider for about 5 years.

When I first applied to MassHealth, a psychiatric NP could not become a MassHealth provider, that only a primary care provider could be.

Thus the QMB status has worked well to cover whatever Medicare does not for dual eligible persons.

Problem of Medicaid provider status vs QMB reimbursement

Last July, the clinic where I am employed part time strongly encouraged me to become an actual MassHealth provider. I do not know what policy change occurred to allow this.

I believe this is limited to NPs.

I was led to believe that this would be better for my private practice, as well as for the clinic, as they are working on Meaningful Use (MU) incentives.

I hoped that this would cover those times that my patients had a lapse in their mental health plan (MCO), but still had masshealth standard.

They had to credential me, in order for them to certify my work for MU.

Much effort, many phone calls, many signings of paperwork went into this, and I was approved as of December 2015.

Masshealth provider enrollment told me where I could see the rates for the codes on the mass.gov website, nurses getting 85% of MD rate. They did not look bad compared to Medicare.

However, it seems to be a minor disaster.

It has become clear that most of what was covered under QMB is NOT covered by masshealth.

They do not pay co-insurance, and they only pay a percentage of the Medicare deductible. Neither my billing service, nor my contact at the clinic expected this to happen.

This status would be best if I was planning to run a business for primarily straight masshealth clients, which is not at all my population. Most, of course, have an MCO for mental health.

Has anyone else run into this, or have any suggestions what to do?

Thanks in advance!

Sandy Thomaier PMHNP

Greenfield MA

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