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Fee-for-Service Medicaid - State-by-State Billing Rules, Reimbursement, & Common Pitfalls

Name: Cures Medical Billing Services Company
Address: 3811 Ditmars Blvd# 1124, Astoria, NY 11105, Astoria, NY, 11105, USA
Telephone: +1 (917) 994-9941

As a Medicaid billing consultant with 12+ years of experience, I’ve seen firsthand how misunderstandings about fee-for-service (FFS) Medicaid lead to claim denials and lost revenue. As a Medicaid billing specialist who’s helped clinics recover over $1.2M in denied claims.

I’ll break down exactly how FFS Medicaid works, share state-specific tips, and reveal proven strategies to maximize reimbursements.

What is Fee-for-Service Medicaid?

FFS Medicaid is a direct-payment model where providers bill states for each service rendered (e.g., 75forawellnessvisit 75 for a wellness visit, 150 for an X-ray). Unlike managed Medicaid (where insurers pay fixed rates per patient), FFS offers:

Flexibility: No network restrictions any Medicaid-certified provider can participate.
Transparency: Payments align with service complexity (e.g., higher reimbursement for surgeries).
Control: Direct claims submission to state Medicaid programs (no middlemen).

Example: A Michigan pediatric clinic increased revenue by 18% after switching from managed Medicaid to FFS, billing for 92% of eligible services.

FFS Medicaid vs. Managed Medicaid - Key Differences

Factor	FFS Medicaid	Managed Medicaid
Payment Model	Paid per service (e.g., $120 for CPT 99214)	Fixed monthly payment per enrolled patient
Prior Authorization	Rarely required (varies by state)	Often mandated for specialists
Provider Networks	Open to all Medicaid-certified providers	Limited to the plan’s contracted network
Claim Denials	Often due to coding errors or eligibility lapses	Common due to network or prior auth issues

Case Study: A Florida FFS provider reduced denials by 65% after using the state’s MediPass portal to verify eligibility pre-visit.

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Step-by-Step Guide to Billing FFS Medicaid

Enroll as a Medicaid Provider
- Complete state-specific forms (e.g., NY’s eMedNY, CA’s Medi-Cal).
- Submit licenses, NPI, and IRS documents. Average processing: 30–90 days.
Verify Patient Eligibility
- Use tools like Virginia’s Cover VA or Ohio’s ODM portal.
- Check for coverage limits (e.g., Texas caps physical therapy at 30 visits/year).
Code Accurately
- Follow state-specific codes (e.g., Michigan requires POS 11 for office visits).
- Link CPT codes to ICD-10 (e.g., CPT 99213 + Z00.00 for routine exams).
Submit Claims
- Use CMS-1500 forms or state portals (e.g., Nevada’s Medicaid Management System).
- Include modifiers (e.g., -25 for separate E/M services).
Track Payments & Appeals
- Most states pay within 30–60 days.
- Appeal denials with proof of eligibility or corrected codes.

State-Specific FFS Medicaid Rules (2024)

Michigan
- Reimbursement: 62for99213,62for99213,220 for 29881 (knee arthroscopy).
- Prior Auth: Required for DME over $500.
Ohio
- Lookup Tool: ODP Provider Search.
- Acute Care: Bill with modifier -ER for emergency services.
Florida
- MediPass: Mandatory provider directory for FFS.
- Therapy Limits: 24 visits/year for adults.
Nevada
- Fee Schedule: Publicly posted (e.g., $85 for 99214).
- Telehealth: Reimbursed at 100% of in-person rates.
Virginia
- Documentation: Require Z79.4 for insulin-dependent patients.
- Denial Rate: 22% for missing prior authorization (highest in the U.S.).

Top 5 FFS Medicaid Denial Reasons & Fixes

Eligibility Lapses
- Fix: Verify eligibility 24 hours before appointments.
Incorrect POS Codes
- Fix: Michigan: POS 11; ER: POS 23.
Missing Modifiers
- Fix: Append -GT for telehealth in Texas.
Outdated Fee Schedules
- Fix: Check state updates quarterly (e.g., Medi-Cal’s July 2024 changes).
Timely Filing
- Fix: Submit within 90 days (most states).

FFS Medicaid Reimbursement Rates by Service

CPT Code	Service	MI	OH	FL
99214	Office Visit (Moderate)	$62	$58	$55
90837	Therapy (60 mins)	$75	$70	$68
73562	X-ray (Knee)	$45	$42	$40

Conclusion

Fee-for-Service (FFS) has been a foundational price model in healthcare for decades. While it gives many advantages, particularly in presenting a clean and flexible fee structure, its ability for overuse and rising expenses are driving the shift towards more cost-based alternatives.

FFS Medicaid offers flexibility but requires state-specific compliance.
Eligibility checks and accurate coding prevent 80% of denials.
Reimbursement varies widely—always review your state’s fee schedule.

Need Help? Book a free 20-minute Medicaid billing aduit

Frequently Asked Questions (FAQs)

What is acute care FFS Medicaid?

Covers ER, urgent care, and inpatient hospital services billed per procedure (e.g., CPT 99285 for ER visits).

How do I bill FFS Medicaid in Ohio?

Use ODM-approved codes (e.g., H0031 for mental health) and submit via ODM portal.

Can I participate in both FFS and managed Medicaid?

Yes, but patients must be enrolled in FFS to bill the state directly.

What’s the reimbursement rate for 99213 in FFS Medicaid?

Varies by state—45inCalifornia, 45inCalifornia,58 in Virginia (check your state’s fee schedule).

What does fee-for-service Medicaid cover?

Fee-for-service (FFS) Medicaid covers medically necessary services billed per procedure, including:

Primary care: Office visits (CPT 99213), vaccinations.
Specialty care: Surgeries (e.g., CPT 47562 for gallbladder removal).
Emergency services: ER visits (CPT 99285), urgent care.
Diagnostics: X-rays (CPT 73562), lab tests.
Therapies: Physical therapy (CPT 97110), mental health counseling.

State Variations:

Florida: Limits therapy to 24 visits/year for adults.
Nevada: Covers telehealth at 100% reimbursement.
Virginia: Requires ICD-10 Z79.4 for diabetic patients on insulin.

What is the meaning of fee for services?

Fee-for-service” (FFS) is a payment model where providers are paid per service rendered, not per patient or timeframe. For example:

A doctor bills $75 for a check-up (CPT 99213).
A hospital bills $1,200 for an MRI (CPT 70553).

This contrasts with managed care (fixed monthly payments per patient) and emphasizes volume over outcomes.

How does a fee-for-service plan work?

Provider Enrollment: Clinics register with state Medicaid (e.g., NY’s eMedNY).
Service Delivery: Provide care (e.g., surgery, therapy).
Billing: Submit claims with CPT codes (e.g., 99214) and ICD-10 diagnoses (e.g., I10 for hypertension).
Payment: State Medicaid reimburses per service (e.g., $58 for 99214 in Ohio).

Example: A Michigan clinic bills $62 for a 99213 visit and receives payment in 30 days.

What are the disadvantages of fee-for-service?

Administrative Burden: High denial rates (e.g., 22% in Virginia) due to coding errors.
Delayed Payments: States like Florida take 60+ days to process claims.
No Prior Auth Safety Net: Services like DME in Michigan require prior auth retroactively, risking denials.
Fraud Risks: Overbilling for unnecessary services.

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Your Success Is Our Success

We are a team of national medical billing service experts based in Astoria, NY, committed to providing ongoing value to our customers. We leverage technology and implement best practices to provide high-quality and cost-efficient medical billing solutions from domestic locations, enabling customers to achieve their business goals. Cures Medical Billing is the best option for any medical billing needs.

At Cures Billing Services, we prioritize collaboration and recognize the uniqueness of each healthcare provider or organization
Maximize your revenue by focusing on growing your practice and let us handle all the back-end billing processes.
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Medical billing around Astoria, NY, and beyond is our core competency and our specialists will efficiently manage all your billing needs. Our medical billing specialists have over 12 Plus years of experience with all security technologies to ensure data integrity for our customers. Using our medical billing service, anyone can make their medical billing task less resource-consuming.