Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMB) for Medicare Cost-Sharing
From: CMS Transmittal 1747 (Pub 100-20) – 11/4/16
SUMMARY OF CHANGES: The purpose of this Change Request is to instruct Medicare Administrative Contractors (MACs) to accept Beneficiary Contact Center (BCC) referrals of beneficiary inquiries involving Qualified Medicare Beneficiary (QMB) billing problems, issue Compliance letters to named providers and send a copy of the provider Compliance letter to the named beneficiary with an explanatory cover letter.
Federal law bars Medicare providers from charging Qualified Medicare Beneficiary Program (QMB) individuals 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. Sections 1902(n)(3)(C); 1905(p)(3); 1866(a)(1)(A); 1848(g)(3)(A) of the Social Security Act.
Effective, September 19, 2016, Beneficiary Contact Center (BCC) Customer Service Representatives (CSRs) will implement protocols to identify a caller’s QMB status and advise them about QMB billing protections. Within 30 days of implementing this Emergency CR, BCC CSRs will escalate certain beneficiary inquiries involving improper QMB billing to the appropriate MAC through the Next Generation Desktop (NGD) in accordance with the Complex Inquiry Escalation National Operating Procedures. MACs are instructed by CMS to issue a compliance letter within applicable complex inquiry timeframes (within 25 business days for at least 75 percent and within 45 business days for 100 percent of all inquiries referred) instructing named providers and suppliers to refund any erroneous charges and recall any past or existing billing