Reminder about Billing Requirements for Certain Dual-Eligibles

The American Medical Association is reminding physicians that Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program cannot be balanced billed for services, including deductibles, co-insurance and co-payments. The Centers for Medicare & Medicaid Services (CMS) has voiced concern that some physicians are still billing QMB beneficiaries, despite a federal law that prohibits them from doing so.

The QMB Medicaid program helps very low-income dual-eligible beneficiaries with Medicare cost-sharing. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances).

Physicians may be subject to sanctions for failing to follow these billing requirements. And, CMS has indicated that they may start conducting more frequent audits to address this practice.

For more information, click here to see CMS’ MLN Matters, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program. 

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