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Qualified Medicare Beneficiaries (QMB) claims processing update from CMS

Recently, the Centers for Medicare & Medicaid Services (CMS) announced they would re-introduce the QMB information in the Medicare Remittance Advice (RA) and Medicare Summary Notice (MSN) to providers.  This began with claims processed on or after October 2, 2017.

IMPORTANT:  Patients who have QMB status have zero cost-sharing liability and balance billing these individuals is strictly prohibited.  This delay on the RAs and MSNs does nothing to change that.

CMS announced that these notices on RA and MSN were suspended because they were causing some issues for states and other secondary payers.  CMS notes in MM10433 the following:

On December 8, 2018, CMS suspended CR 9911 to address unforeseen issues preventing the processing of QMB cost-sharing claims by States and other secondary payers outside of the Coordination of Benefits Agreement (COBA) process … CR 10433 reinstates all changes … under CR 9911. Please make sure your billing staff is aware of these changes.

CMS goes on to emphasize the prohibition on balance billing QMB status individuals:

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 … The QMB program is a State Medicaid benefit that assists low-income Medicare beneficiaries with Medicare Part A and Part B premiums and cost-sharing, including deductibles, coinsurance, and copays. In 2015, 7.2 million individuals (more than one out of 10 beneficiaries) were enrolled in the QMB program.  Providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. However, as permitted by Federal law, States may limit Medicare cost-sharing payments, under certain circumstances. Be aware, persons enrolled in the QMB program have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing.

 The revised Alert RARCs are as follows:

  • N781 – Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
  • • N782 – Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.

We are happy to assist providers and groups with revalidation, payer appeals, chart reviews, compliance, or other documentation and coding concerns.  Please contact us via one of the below or on our “App”, Corcoran 24/7, which can be accessed via your app store. (800) 399-6565

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