Mario Fucinari DC, CCSP, APMP, CPCO

Recently, the Centers for Medicare and Medicaid Services (CMS) once again clarified the Qualified Medicare Beneficiary (QMB) billing requirements. Even if you are not a provider for Medicaid or covered services under Medicare are not covered by Medicaid in your state, you must still adhere to the billing requirements.

All original Medicare and Medicare Advantage providers and suppliers – not only those that accept Medicaid – cannot charge patients enrolled in the QMB program for portions of Medicare, usually the responsibility of the patient.  This would include patient cost sharing items, such as coinsurance, deductibles, and co-pays.

Despite these billing rules, a July 2015 study found that the patients in the QMB program are still being wrongly billed and that confusion about billing rules continues. Many beneficiaries are unaware of the billing restrictions (or concerned about undermining provider relationships) and simply pay the cost-sharing amounts.  Federal law bars Medicare providers and suppliers from billing an individual enrolled in the QMB program for Medicare Part A and Part B cost-sharing under any circumstances (see Sections 1902(n)(3)(B), 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act [the Act]). Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions.

To qualify for the QMB program, a patient must be eligible for Medicare Part A and have an income not exceeding 100% of the federal poverty level (FPL).  People with Medicare who are in the QMB program are also enrolled in Medicaid and get help with their Medicare premiums and cost-sharing. The Medicaid program is state-controlled.  Certain states do not cover chiropractic spinal manipulation or other services.  In these states, even though the provider cannot seek reimbursement from Medicaid even if they were enrolled in Medicaid, the provider may not collect the co-pay or deductible for covered services. When the patient is in the QMB program, they have no legal obligation to pay Medicare providers for Medicare Part A or Part B cost-sharing.

Providers should establish steps to follow QMB Federal law.

1. Establish processes to routinely identify the QMB status of your patients prior to billing.

Medicare providers and suppliers can readily identify the QMB status of patients and billing prohibitions from the Medicare Provider Remittance Advice, which will contain new notifications and information about a patient’s QMB status. Medicare Advantage (Part C) providers and suppliers should also contact the Medicare plan to learn the best way to identify the QMB status of plan members.

2. Establish billing procedures with your staff and your clearinghouse.

Clearly document your policies and procedures and place them in your compliance manual (required by law) to exempt QMBs from Medicare charges and remedy billing problems should they occur. If you have erroneously billed an individual enrolled in the QMB program, recall the charges (including referrals to collection agencies) and refund the invalid charges they paid.

3. Establish procedures for correct Advance Beneficiary Notice (ABN) policies.

Providers give an ABN in order to transfer potential financial liability to a Medicare beneficiary before providing a Medicare-covered item or service that is expected to be denied by Medicare because it is not medically reasonable and necessary or custodial care. If the provider has any indication that the beneficiary is a dually eligible beneficiary (has QMB and/or Medicaid coverage) special guidelines apply.

According to CMS, when the beneficiary signs the ABN, they must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication. This is the only instance where the provider may indicate what option the beneficiary should choose.

Even though the ABN indicates the beneficiary may be asked to pay now and is responsible for the payment if Medicare doesn’t pay, the provider cannot bill the dual eligible beneficiary when the ABN is furnished. Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid considering federal laws affecting coverage and billing of dual eligible beneficiaries. If Medicare denies a claim as not medically reasonable and necessary and a Remittance Advice (RA) is received, the claim may be crossed over to Medicaid for adjudication, depending on State Medicaid coverage and payment policy. Medicaid will issue an RA based on this determination.

Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the beneficiary in the following circumstances.

      • If Medicare denies the claim as not reasonable and medically necessary and the beneficiary has QMB coverage without full Medicaid coverage, the ABN would allow the provider to shift liability to the beneficiary per Medicare policy.
      • If Medicare denies the claim as not reasonable and medically necessary for a beneficiary with full Medicaid coverage, and subsequently, Medicaid denies coverage (or will not pay because the provider does not participate in Medicaid,) the ABN would allow the provider to shift liability to the beneficiary per Medicare policy, subject to any state laws that limit beneficiary liability.

4. Billing a QMB for services that are statutorily excluded services that Medicare never covers.

If Medicare expressly excludes coverage for a given item or service, such as examination and therapy when performed in the chiropractic office, and the beneficiary has QMB coverage without full Medicaid coverage, the provider could bill the beneficiary for the full cost of care.

Please keep in mind that for statutorily excluded services that Medicare never covers, an ABN does not have to be issued. However, I encourage providers to issue an ABN or other forms, so they are aware of their potential financial liability.

Although the regulations may seem burdensome, keep in mind that the percentage of your patients who are eligible for the QMB program, may be small when compared to your entire patient base.  I recommend that you discuss this article with your staff and other providers and establish policies to properly handle QMB patients as they may present to the office.


Mario Fucinari DC, CCSP, MCS-P, CPCO is a Certified Professional Compliance Officer, Certified Medical Compliance Specialist and a member of the Medicare Carrier Advisory Committee.  He is a frequent national speaker for ChiroHealthUSA, NCMIC and Foot Levelers.  Dr. Mario has been in full-time practice in Decatur, IL since 1987. To request Dr. Fucinari to speak for your organization or to utilize Dr. Fucinari and his team of certified compliance and coding specialists, please contact him at doc@askmario.com or visit his website at www.Askmario.com for his course schedule, products, and services.

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