CMS auditing physicians who inappropriately bill Medi-Medi patients

December 21, 2016
Area(s) of Interest: Fraud & Abuse 

The Centers for Medicare and Medicaid Services (CMS) recently instructed Medicare contractors to begin issuing compliance letters to physicians who inappropriately bill Qualified Medicare Beneficiaries (QMB) for Medicare cost-sharing. QMB is a Medicaid program that assists low-income beneficiaries with Medicare premiums and cost-sharing.

Federal law bars Medicare providers from charging QMBs for Medicare Part A and B deductibles, coinsurances or copays. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB individual. Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions.  

A July 2015 CMS study found that, despite federal law against the practice, erroneous balance billing of QMB individuals is relatively commonplace and that confusion about billing rules persists among providers and beneficiaries.

CMS has increased its policing activities of inappropriate billing and has engaged in new protocols to verify that physicians know the billing rules and that beneficiaries are educated about their rights and protections under federal law.

Physicians found to be in violation of the federal law prohibiting balance billing of QMBs will receive a compliance letter from their Medicare contractor, instructing them to review their records for efforts to collect Medicare cost-sharing from QMBs, to recall any past or existing billing (including referrals to collection agencies) and to refund to the patients any amounts already paid.

Patients will also receive letters from the Medicare contractor informing them of their rights.

Physicians are urged to ensure that their billing staff are aware of these rules and that their billing software exempts individuals enrolled in the QMB program from all Medicare cost-sharing billing and related collection efforts.

For more information, see the California Medical Association (CMA) “Ask the Expert: Billing Medi-Medi patients” resource, available free to members in CMA's online resource library. Additional details can also be found in Medicare Learning Network (MLN) Matters® article "Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program."

If you have questions, please contact California's Medicare contractor, Noridian, at (855) 609-9960.


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