Medicare Compliance & Reimbursement

As Medicare shifts from fee-for-service and instead focuses on quality, value-based care under MACRA, CMS continues to push through mandates that protect the beneficiary from nefarious providers and suppliers.

In a Nov. 18, 2016 MLN Matters article (MM 9817), a change request was made concerning keeping in compliance when billing a Qualified Medicare Beneficiary (QMB). The initiation of the QMB program, which falls under the realm of Medicaid, was to “assist low-income beneficiaries with Medicare premiums and cost-sharing.” CR 9817 urges MACs to send out compliance letters to providers who persist in overbilling QMBs.

Due to confusion regarding the rules of billing under the QMB program, many providers send bills to beneficiaries without a thorough understanding of their coverage under the plan. A study done by CMS in July of 2015 found that both parties did not fully understand what can be billed and how it should be paid. Currently, CMS encourages QMB beneficiaries confused about their billing rights to call Beneficiary Contact Center (BCC) at 1-800-MEDICARE.

The compliance letters will be sent out after errors have occurred involving the provider or supplier and the beneficiary, instructing providers on how to refund charges to these patients.

“Medicare providers must accept Medicare payment and Medicaid payment (if any) as payment in full for services given to individuals enrolled in the QMB program,” CR 9817 says. “Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions.”

For more information on this new QMB compliance issue, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9817.pdf.