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Experience. Integrity. Advocacy.

Billing for Qualified Medicare Beneficiaries and What Not to Do

Billing for Qualified Medicare Beneficiaries and What Not to Do

Did you know providers who bill Qualified Medicare Beneficiaries (QMB) for copays or deductibles could be subject to sanctions by the Centers for Medicare and Medicaid Services (CMS)?

QMBs are one type of dual-eligible Medicare beneficiary who qualify for both Medicaid and Medicare. According to WPS-GHA, Indiana’s Medicare Administrative Contractor, providers can bill Medicaid for the cost-sharing balances but are prohibited from billing the beneficiary. “Providers and suppliers, including pharmacies, may bill State Medicaid agencies for Medicare cost-sharing amounts,” says the WPS-GHA Qualified Medicare Beneficiary (QMB) Program webpage. “However, as permitted by Federal law, States may limit Medicare cost-sharing payments, under certain circumstances.”

Whether from ignorance or an attempt to skirt the law, many providers still bill QMBs for cost-sharing services, according to CMS.

“Many beneficiaries are unaware of the billing restrictions (or concerned about undermining provider relationships) and simply pay the cost-sharing amounts. Others may experience undue distress when unpaid bills are referred to collection agencies,” the agency says in 2018 MLN Matters.

To avoid accidentally billing a QMB after Medicare pays for the services, CMS recommends a few best practices.

Enroll with Medicaid

First, be sure you are enrolled with your state’s Medicaid program so that you can submit claims for your QMBs. Though not surprising, “States require providers to enroll in their Medicaid systems for claim review, adjudication, processing, and issuance of Medicaid RAs for payment of Medicare cost-sharing,” CMS explains in a recent issue of MLN Connects.

Check Eligibility

Second, make every effort to identify QMBs prior to submitting claims by creating a routine process for checking beneficiaries’ eligibility. This will allow you find QMBs who haven’t self-identified at the time of service. Try using any of the following methods:

Confirm with Remittance Advices

Next, confirm eligibility information following Medicare claim adjudication by checking Medicare Remittance Advices (RAs). If the beneficiary is a QMB, any cost sharing amounts will be accompanied by one of the following Remittance Advice Remark Codes:

  • N781 – Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer, or
  • N782 – Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.

Don’t Forget MA Plans

Also, these billing restrictions for QMBs appliy to dual-eligible beneficiaries who have Medicare Advantage (MA), too. Contact MA plans you work with to learn how to identify the QMB status of their plan members prior to and following claims submission.

Correct Any Errors

Finally, if you do bill a QMB for cost-sharing amounts, correct the error immediately. CMS recommends not only refunding any amounts the QMBs might have paid, but also recalling the charges, “including referrals to collection agencies.”

More Information

For more information about billing for services provided to Qualified Medicare Beneficiaries and the restrictions on collection cost-sharing amounts, review the following resources:

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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