Payer of Last Resort (PLR) for CHC Billing

Categories: Billing, CHC, PMG Insights Blog

October 21, 2013

Anyone familiar with CHC healthcare knows the front desk is a pivotal place. From patient reception to scheduling to phone calls to eligibility verification to patient placement… the list goes on. A significant risk area, and one that gets too little attention, revolves around compliance with Payer of Last Resort (PLR). PLR simply compels a CHC to be certain to bill third party payers in the appropriate order. For instance, a patient with Blue Cross Blue Shield (BCBS) who is also eligible for and therefore covered by Medicaid would see his/her claims go to BCBS first and Medicaid next. Makes sense, right? Why should our tax dollars (which fund Medicaid) pay before BCBS?  BUT, with many states offering easy to use presumptive eligibility options and CHC staff familiarity with state Medicaid, often only Medicaid or a grant funded program (e.g., Ryan White or Title X) is billed without ever even asking a patient if they have other insurance.  This is not only a violation of PLR BUT creates real liability for CHCs in the event of an audit. Remember, Medicaid is ALWAYS the Payer of Last Resort unless you see something in writing (preferably from an official source) stating otherwise.