The federal government is concerned about erroneous balance billing practices as they relate to qualified Medicare beneficiaries. As a result, in February 2016, Medicare revised its MedLearn Matters article, SE1128, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program, indicating: “Federal law bars Medicare providers from balance billing a QMB beneficiary under any circumstances.” See Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.
QMB is a Medicaid program for Medicare beneficiaries that exempts them from liability for Medicare cost sharing. State Medicaid programs may pay providers for Medicare deductibles, co-insurance and co-payments. However, as permitted by federal law, states can limit provider reimbursement for Medicare cost sharing under certain circumstances. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary. Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. (See Sections 1902(n)(3)(C); 1905(p)(3); 1866(a)(1)(A); 1848(g)(3)(A) of the Social Security Act.)
Providers who participate in traditional Medicare and Medicare Advantage Plans (not only those that accept Medicaid) must follow all of their balance billing exclusions. It is vital that front- and back-office staff members understand the process of balance billing and exclusions for Medicare and private carriers. It is also significant to know the billing process if a patient has dual coverage, whether it is with commercial insurance and/or Medicare. The Balanced Budget Act of 1997 prohibits the collection of cost-share amounts directly from dual-eligible individuals (i.e., individuals who have both Medicare and Medicaid). Providers who serve patients who are dually eligible must either accept the payment received as payment in full or seek reimbursement for any cost share from the appropriate state source. For additional information on dual eligibility, visit the CMS website.
To avoid any and all confusion with patient responsibility and uncovered services, it is important for practices to diligently strive to inform patients of their covered services versus what the insurance will pay or will not pay for. The financial impact of writing off charges due to denied claims or patients disputing a bill is inconvenient and inefficient. Physicians and practice managers should review and update all documents and software that are used to capture charges to avoid any outstanding charges in accounts or write-offs. Taking the necessary proactive steps to protect your practice’s financial status is necessary.
