Am I allowed to balance bill dual eligibles (Medicare as primary, Medicaid as secondary)

I’m par with Medicare, non-par Medicaid.  If I have a patient who is Medicare primary, Medicaid secondary, am I allowed to balance bill them for the portion not covered by Medicare?  Or do I need to write this off?

There are a lot of misunderstandings about billing patients with Medicare as primary and Medicaid as secondary, also known as dual eligibles. Medicare pays 80% of the allowed amount and in most states Medicaid pays nothing- because their allowed amount is under 80% of the Medicare allowed amount. As a reminder, hold the claims until the deductible has been met.

Some physician offices chase after the patient for the remaining 20%. Other docs have said it’s illegal to do so and these offices are in the wrong. The truth really depends on if the patient is a QMB- a qualified Medicare beneficiary.

There are many different categories of Medicaid. To be specific three of them- QMB, SLMB, and QI:

A dual beneficiary has Medicare as primary and Medicaid as secondary. Balance billing is not prohibited for ALL medi- medi patients. Rather it is prohibited for QMB patients. Here’s Ho Sun’s commentary on how to maximize your revenue in this situation.

Balance billing of QMBs is something that the OIG is paying attention to and can sanction offices who improperly bill the patient, so don’t do it:

The prohibitions against balance billing are only for QMBs. Therefore you CAN balance SLMB and QI. Read the fifth to last sentence:

So when a individual presents their Medicaid card, verify in your state’s website that they are truly a QMB and not a QI or SLMB.

So then someone asked about writing off the 20% for QI and SLMB:

I don’t know if writing it off is necessarily correct. If you do not participate and tell the patient upfront that they are responsible for the 20% and the patient agrees than I don’t understand why the patient shouldn’t be responsible.  People with Medicaid are allowed to go out of network and pay privately.  If you are non par with Medicaid than you are out of network. Just be upfront with the patient and make sure they know you are non par with Medicaid.

If you don’t attempt to routinely collect the 20% coinsurance for all patients (who don’t have a supplement that covers it) and document efforts, you will definitely run afoul of Medicare’s rules (specifically the anti kickback statute and false claims act; it’s seen as a form of inducement).

However, the OIG has allowed some safe harbor guidelines to the rules in paragraph 5 in the link below- specifically if the waiver is not done routinely, not advertised, and there is determination that the individual is indigent:

So you can CHOOSE to waive the coinsurance or deductible on SLMBs and QI dual eligible. But you aren’t REQUIRED to.

You could use the patient’s SLMB or QI eligibility as a proxy for being indigent.

Another alternative is to have the patient fill out a hardship form, here’s an example:

Generally when someone presents with a out of state Medicaid card I don’t bother verifying QMB status and just forgive the coinsurance (as long as their Medicare eligibility is OK).

Also, the American Academy of Ophthalmology has a volunteer program called EyeCare America to see indigent patients. I encourage everyone to join. There is no patient responsibility: you waive the 20% coinsurance on patients with Medicare as primary (most patients).

So if you’re non par with Medicaid can you collect the 20% for QMBs?

The answer is no.

I wanted to share this excellent slide deck:

Even if you aren’t enrolled or on par with Medicaid, you still can’t collect coinsurance from QMBs as long as you are enrolled with Medicare. It doesn’t matter if you’re non par with Medicaid. If you are not participating with Medicare then obviously there’s an exception.  (See slides 14-16 above)

So then someone stated:

I think this rule is a terrible disservice to medicaid dial eligibles. It encourages providers to turn them away from any services.

Assuming that the folks who made the slide deck are correct, this is actually right. If someone is enrolled in traditional Medicare with Medicaid as secondary, an office can choose to not see them (slide 20 above).

Personally, I don’t turn away dual eligibles. Part of this is the overwhelming majority of patients in this situation are very appreciative of my office and being able to get care.

Just like everyone else I wish I got paid more for my services, but I guess this is my way of giving something back. If Medicare rates dropped to the point where 80% of Medicare is unsustainable then I’d definitely reconsider this policy.

However, Medicare advantage programs differ in terms of being able to turn away patients. If the dual eligible QMB is enrolled in a advantage plan with cost sharing, the doctor can’t collect the copay (prohibition of balance billing on QMBs), but also can’t refuse to see the patient (Medicare advantage plans but not traditional Medicare have protections against discrimination specifically on the basis of payment). The EOB from the MA plan should be sent with a CMS 1500 to Medicaid, and any further balance is not collectible. (Slides 21-24)

Then is it illegal to see a QMB enrolled in a managed program out of network and bill them? Isn’t this the same as balance billing of a QMB?

A lot of us wonder if a QMB patient is enrolled in a managed medi-medi plan (let’s say through Ho Sun’s IPA with a San Jose network) and gets a eye problem in Arizona and wants to see me. Does the prohibition of balance billing of QMBs extend to this scenario?

According to slide 28 in the link above, if a Medicare advantage member goes out of network, then it’s a non Medicare covered service- which is not covered by balance billing protections. The same applies for refraction- it is not a Medicare covered service.

Of course if the patient had traditional Medicare, you’d get the 80% if the deductible has been met, and eat the remaining 20% even across state lines.

Finally, BEWARE of individuals presenting with a Medicare card and Medicaid secondary. ALWAYS verify in your PM system that they aren’t in a managed Medicare/ Medicaid replacement plan with a limited or narrow network- or you will get paid zero and can’t bill the patient!

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