08/15/2016

Are You Violating the Medicare Billing Laws?

Federal officials recently warned doctors may be subject to penalties if they persist in these practices. They could, for example, be fined or excluded from Medicare.  Federal officials report doctors are improperly billing poor people on Medicare for deductibles, co-payments and other costs from which they are supposed to be exempt.

The people who are being billed improperly are “qualified Medicare beneficiaries” who are also enrolled in Medicaid and have very low incomes, generally less than $1,010 a month for an individual or $1,355 for a married couple.

Federal law says that such beneficiaries do not have “any legal liability to make payment” to a doctor or a hospital beyond the amounts paid by Medicare and Medicaid. Federal officials recently informed doctors that they “must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a qualified Medicare beneficiary.

Despite this requirement, a study by the Department of Health and Human Services found that improper billing still appears to be “relatively commonplace” because “some Medicare providers unlawfully bill enrollees” after receiving payments from Medicare and Medicaid. Many low-income beneficiaries are unaware of the billing restrictions or are concerned about losing access to their doctors, so they “simply pay the cost-sharing amounts.”

About seven million low-income people receive financial help through the program for qualified Medicare beneficiaries. Under this program, state Medicaid agencies help pay Medicare premiums, deductibles, co-payments and coinsurance. States do not have to pay doctors the full amount of such costs, and in some cases they pay nothing, leaving doctors with hundreds or thousands of dollars in unreimbursed expenses.

Doctors say they do not always know that a patient is a qualified Medicare beneficiary and is therefore exempt from Medicare’s cost-sharing requirements. The government has recently stated it is increasing efforts to educate doctors and patients after finding widespread confusion. 

The law governing the billing of ‘Qualified Medicare Beneficiaries’” is not new!  Federal law dating back to the 1990’s allows states the option of making payments based on their Medicaid rates rather than on Medicare rates, which saves them money.  Medicaid payment rates for physician services are often well below Medicare’s — a reason that some doctors cite for refusing to participate in Medicaid or for limiting the number of Medicaid patients they will see.

The federal government has warned doctors that if they participate in Medicare, they “must abide by the balance-billing prohibitions,” regardless of whether they also accept Medicaid patients. “Medicare providers who violate these billing prohibitions are violating their Medicare provider agreement and may be subject to sanctions”.