More on Inappropriate Billing for Dual-Eligible Beneficiaries

Tim Engelhardt, director of the Medicare-Medicaid Coordination Office (MMCO) at CMS, recently spoke to Physicians Practice on the nuances of collecting patient copays for dual eligible beneficiaries and the legalities of not billing and collecting correctly.

Engelhardt and his office works to coordinate services within dual eligible beneficiaries. Within the dual eligible population, there are roughly 7 million individuals who receive financial help with Medicare cost sharing through the Qualified Medicare Beneficiary Program (QMB). The lesser-known QMB program, which is administered through state Medicaid offices, has been in place since 1989, and provides financial assistance for certain groups of low-income adults over the age of 65, eligible adults of any age who are physically or mentally disabled, and individuals with severe mental illness. Medical practices and service providers are prohibited from balance-billing QMB beneficiaries by federal law for any outstanding charges.

*Editor's note: for federal guidance on the prohibition against balance billing QMB beneficiaries, read MLN Matters: SE1128 Revised at bit.ly/no-balance-billing.

Physicians Practice recently spoke with Engelhardt in a two-part interview about common misperceptions concerning the QMB program, held by physicians, medical billers, and even program participants. Below is part two of the interview. Part one can be found here.

PP: What happens if a provider incorrectly bills QMB beneficiaries for Medicare cost sharing? Is that a red flag?

TE: Let me answer that in a couple different ways. What happens if [physicians] bill a beneficiary? The first answer is there is a significant risk if a beneficiary who already has extremely low income, less than $12,000 a year, is going to pay an amount that is forcing them to make a pretty difficult life decision relative to other things that are necessities for someone at that level of income. It's also a point of some significant confusion and distress, for those people. It is not an inconsequential challenge. And certainly there are other people who will get a bill and know that they don't have to pay it. That's fine. But we've also seen the debt collection angle. And so our primary focus has been on the beneficiary impact and that's the most concerning one. Is it a red flag for CMS? Absolutely it is a red flag for CMS. It is inappropriate billing. But our primary focus right now is on education and outreach and improving compliance. And that is why in part we wanted to make sure we had the opportunity [to speak with Physicians Practice].

PP: What is the billing process for QMB beneficiaries after providers have billed Medicare?

TE: There are some nuances in how the processing actually works. But in the fee-for-service traditional Medicare environment, the provider who's also enrolled in the Medicaid side, that crossover bill for the co-insurance should be crossing over automatically to the state Medicaid agency. There are some instances where that doesn't happen, but that is generally how the process is designed to work. There is a level of important and complicated nuance associated with this. Which is, due to issues in federal law, the state Medicaid agencies are not always required to pay the full cost sharing amount. So in some instances, the provider might do everything right and they just receive zero or limited payment from the state Medicaid agency. Of course, that's sub-optimal from a physician practice, revenue management perspective. But it doesn't change the fact that even when the Medicaid agency doesn't make the full payment, the QMB protections remain in place. And they still can't bill the beneficiary even in that particular instance. So yes, the primary mechanism is the copayment made by state Medicaid agencies.

PP: So it is incumbent on medical practices to identify QMB beneficiaries. But how do they do that?

TE: So, QMB beneficiaries have a card. And that is something that a practice should be asking for. Those cards look a little bit different from state to state. Providers can also contact the Medicaid agency to find out if they can query the state Medicaid system (many practices can already do this) to check [for QMB enrollment].

PP: That would be additional work for practices, yes?

TE: There's no doubt that effectively complying with the law in this instance requires some careful steps at the point of intake and billing. 

PP: Do you find that the QMB population is typically concentrated in specific regions of the country?

TE: It is a function of low income and certainly there are varying amounts in different parts of the country. But I think one thing is true, there is a significant concentration of QMB everywhere in this country. And it is very true in rural areas, but it is also very true in major urban hubs as well. I'm sure there is some demographic variability, but I really think this is an issue that is of meaningful prevalence from coast to coast. 

PP: What are your recommendations to providers, so they can correctly identify and bill services for QMB beneficiaries?

TE: I really think it starts with a self-assessment of the billing process to ensure that the billing process has indeed a check in place to test for compliance with the QMB protections. And that means, "Are we adequately identifying individuals," "Where do we identify them," "Are we billing appropriately?" I think it starts there.