Coding & Reimbursement

QMB — another reimbursement trap

What you need to know to stay out of trouble when a patient is dually-eligible for both Medicare and Medicaid.

By Suzanne L. Corcoran

Q. What is QMB?

A. QMB (Qualified Medicare Beneficiary) is a state Medicaid benefit established in 1988 that covers Medicare deductibles, coinsurance and copayments. Federal guidelines set an eligibility floor based on the federal poverty level and the value of a beneficiary’s resources. States can choose to make these limits more generous and include more beneficiaries in their program, just as they can expand welfare benefits. In some states, the QMB program also pays the beneficiary’s Medicare premium, especially if there are dual-eligible managed care plans.

Q. Why is the QMB program important to physicians?

A. Under federal law, patients who are enrolled in the QMB program are exempted from liability for Medicare deductibles, coinsurance or copayments (collectively, “cost-sharing”). You may not charge or collect any amount from these patients under any circumstances. To balance-bill these patients would be a violation of your Medicare provider agreement, and could subject you to sanctions.

The QMB program applies to Medicare Advantage (Medicare Part C) patients as well as those enrolled in regular Medicare (Part B). This means that you may not collect an Advantage Plan copayment either.

Q. We are not Medicaid providers; what then?

A. Even if you are not enrolled as a Medicaid provider, you are still subject to the QMB limitations. Since Medicaid will not pay you if you are not enrolled, Medicare cost-sharing balances must be written off.

Q. What if Medicaid doesn’t pay?

A. States may limit their liability to providers, usually by setting their fee schedules at or below the Medicare payment amount. Even if Medicaid doesn’t pay, you are still prohibited from charging QMB individuals for Medicare cost-sharing and must write off the balance.

Q. We sometimes get out-of-state patients; what then?

A. QMB individuals retain their protection from balance-billing when they cross state lines to receive care. You may not balance-bill QMB patients even if their Medicaid is provided by a state other than the state in which care is rendered.

Q. Does this apply to us if we are not participating with Medicare?

A. Yes. The QMB program applies to all Medicare providers, both participating and non-participating. Further, you are obliged to accept assignment on all services to these patients even if you would not do so otherwise. Accepting assignment means that you agree to accept the Medicare and Medicaid payment as payment in full, regardless of whether Medicaid pays or not.

Q. If a patient wants to pay directly for a noncovered service, are we allowed to collect for that?

A. Maybe, but tread carefully. Remember that many Medicaid programs cover services that Medicare does not, and that Medicare Advantage plans also offer additional coverage (such as routine eye care). QMB patients cannot choose to waive their QMB status and pay Medicare cost-sharing, so you could be accused of balance-billing. Only if you are absolutely sure that a service is not covered could you collect from the patient; we recommend getting something in writing to support you. And, one would have to ask how these patients can qualify as QMB if they have the resources to pay for noncovered services.

Q. What can we do to identify these patients?

A. CMS recommends the following proactive steps to identify QMB individuals and to communicate with Medicaid agencies.

1. Determine effective means to identify QMB patients. Find out which cards or other forms of identification are issued to QMB individuals so you can ask your patients if they have them. Some state systems have on-line inquiry systems to verify QMB enrollment. Contact your Medicare Advantage plans to determine how to identify the plan’s QMB enrollees.

2. Find out what you need to do to bill Medicaid for reimbursement of the beneficiaries’ cost-sharing, as there may be different processes for these patients. Nearly all states have electronic processes with regular Medicare so these claims automatically cross over to Medicaid; you will see this noted on your Medicare remittance advice. Remember that you must be enrolled as a Medicaid provider to receive any payment.

3. Make sure that your billing software and administrative staff exempt QMB individuals from Medicare cost-sharing billing and any related collection efforts. OM

REFERENCE

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.