Qualified Medicare Beneficiaries: What Healthcare Providers Need to Know

Did you know that healthcare providers play a critical role in protecting low-income Medicare patients from unexpected healthcare costs? And when we say low-income Medicare patients, we mean Qualified Medicare Beneficiaries (QMBs), a set of patients under this program who aren’t billed for services that Medicare covers. However, navigating QMBs can be a slippery slope due to compliance issues that can impact patient care.

According to a research report by MMRR, 41% of QMB eligibles are part of the program, with participation higher among the poor and less educated beneficiaries, those in poorer health, rural residents, African-Americans, and Hispanics. As such, healthcare providers have the responsibility to protect them from out-of-pocket expenses while staying compliant.

Curious to know more about QMBs? Let’s dive in and unravel everything you need to know!

What is the Qualified Medicare Beneficiary?

The Qualified Medicare Beneficiary Program is a Medicare savings program that helps patients pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments. To qualify for the program, patients typically must have Medicare Part A coverage. Aside from that, they also need to meet certain income and resource limits, which can vary based on factors such as marital status and geographical location.

If a patient qualifies for QMB, Medicare providers cannot bill them for services that it already covers. But they may still receive a bill for a small Medicaid copayment if applicable. Medicare Part A covers services like inpatient hospital care, skilled nursing facilities, and other select services. The annual deductible amount under this is valued at $1,632 as of 2024. Part B covers outpatient medical care, which comes with a monthly premium of $174.70 and $240 which is annually deductible as of 2024.

The Impact of Improper QMB Billing

The first thing that you need to know as a healthcare provider is that billing of QMBs is prohibited by federal law. Even if you don’t receive full payment from Medicaid, you can’t bill a QMB. If you do, you’d be violating your Medicare provider agreement and obligations under Medicare Part C and will end up being subject to sanctions. The Social Security Act covers every section you need to know in this matter.

However, Medicare providers and suppliers may bill state Medicaid programs for Medicare cost-sharing, although each state may limit cost-sharing payments under certain circumstances. Certain providers or suppliers may also seek payments for unpaid Medicare deductible and coinsurance or copayment amounts as a Medicare bad debt, for which there is a specified billing procedure, which you can check out here for more information on bad debts.

Despite the law, there are still providers and suppliers, including pharmacies, that continue to improperly bill QMBs for Medicare cost-sharing. Many QMBs are unaware of billing restrictions and still pay the cost-sharing amounts. Others may feel distressed when unpaid bills are referred to collection agencies.

How to Ensure Compliance While Billing

To ensure compliance in billing QMDs, here are the steps you need to follow:

1. Verify the QMB status of a patient before billing
2. Identify if the Beneficiary is a QMB and Owes No Medicare Cost-sharing which can be done by:
   • Using the HETS 270/271
   • Accessing the Medicare Administrative Contractor (MAC) Online Provider Portal and MAC Interactive Voice Response (IVR) System. Each MAC offers its own portal, which you can access and register through MAC’s website.
   • Reviewing the provider Medicare RA notices and beneficiary Medicare Summary Notices (MSNs).
   • Using automated Medicaid eligibility-verification systems in the state where the person lives.
   • Ask individuals for proofs such as Medicaid identification cards, MSN, or any other QMB-related documents.
   • Using the Medicare Eligibility Verification transaction (E1 transaction) for pharmacies.
3. Ensure all QMBs are not billed for Medicare charges by either the practice or a third-party vendor. In case a physician has incorrectly billed a patient from the QMB program, all charges (including referrals to collection agencies) should be recalled or refunded.

Wrapping Up

Navigating QMB compliance doesn’t have to be a headache anymore. By staying informed and compliant with QMB billing requirements, you can protect your revenue streams and ensure vulnerable patients get the care they need. And with Atlantic RCM, you do not have to worry about compliance anymore. We specialize in helping you streamline your practice’s revenue cycle, avoiding costly billing errors, and enhancing compliance in every aspect of your work.

Contact us today if you’d like to know more about how we can help you in QMB billing!

Atlantic RCM is one of the leading multi-specialty medical billing companies in USA that serves 25+ major medical billing specialties. Our experts work across your practice in billing, collections and account receivables management, to help you succeed.

Get in touch with the leading medical billing outsourcing company to learn more. Call us at (469) 501-1500 or write to us Info@atlanticrcm.com