Medical Billing Healthpac
Medical Billing Requirements

In latest news, CMS expressed their concern regarding physicians billing Medicare beneficiaries registered with the Qualified Medicare Beneficiary (QMB) program. The QMB initiative is targeted for dual-eligible beneficiaries with very low income, who are registered to both Medicare and Medicaid with the cost-sharing plans offered by Medicare. Nevertheless, many of the beneficiaries are unaware of the restriction on billing and pay the cost sharing amounts to the provider.

QMB is state Medicare benefit, which covers Medicare deductibles; copayment and coinsurance, subject to payment limits of state – which means a state could limit their liability in providing the above payment in certain circumstances. Providers are not allowed to balance the bill for QMB individuals for cost sharing, notwithstanding whether the provider is responsible for full Medicare cost-sharing amounts reimbursed by state.

Typically, dual-eligible beneficiaries have annual incomes less than $12,000. Federal laws protect these dual-eligibles from cost sharing liabilities, and forbid all original Medicare and Medicare Advantage providers, even those who don’t accept Medicaid from billing individuals enrolled to QMB for Medicare copayment, coinsurance, and deductibles.

Every payment from Medicare and Medicaid received by physicians for furnishing services to QMB individuals are fully reimbursed. So, these restrictions for billing apply to every provider, regardless if the agency is liable to reimburse Medicaid the full Medicare cost sharing amount. However, there are some circumstances where the state Medicare program is allowed to cancel out or reduce Medicare cost division reimbursement to QMB by Federal laws.

Medical Billing Consultants
Balance Billing

QMB individuals are able to keep their safety from balance billing when they cross state lines for receiving care. Providers are not allowed to charge QMB beneficiaries even if the benefit is provided by a state other than the state where the care is provided.

Dual-eligibles are not allowed to ignore their QMB status and compensate for Medicare cost sharing. The federal law referenced above surpasses Section 3490.14 of the “State Medicaid Manual,” which is no longer in effect. Following are some practical steps promoting compliance with balance billing prohibitions.

  • Determine an effective way to identify QMB beneficiary among your patients. Learn about the cards issued to QMB individuals and ways to verify with state system.
  • Detect the billing process in your state for Medicare cost sharing. Electronic crossover processes are available in nearly all states to automatically receive Medicare claims.
  • Medicare providers must ensure that their administrative staff and billing software exempts QMB individuals from cost sharing billing by Medicare and related collection efforts.

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