Medicaid Improper Billing

Many of those who have both Medicare and full Medi-Cal are often subject to improper billing practices by their doctors.



Medicare is aware of this issue and did a full research study HERE that highlighted the billing issues faced by those enrolled in the Qualified Medicare Beneficiary programs (QMB). Most of these issues happen in the doctor’s office between the patient and the office billing. If the patient doesn’t know their rights and the resources out there to support them, then they will likely be pressured by the doctor’s office to pay bills they are not responsible for.


What Are Your Rights?

If you are enrolled into the QMB program (aka Full Medi-Cal), then you are not responsible for any bill related to a Medicare covered service from a covered in-network provider. What does this mean? Federal law prohibits any Medicare provider from billing people who are enrolled in the Qualified Medicare Beneficiary (QMB) program for any Medicare covered service. This means that QMB enrolled individuals cannot be billed by Medicare providers for any Service that is covered by Original Medicare.


Some of you may be enrolled in a Medicare Advantage Plan. These same rules will apply to you as well. The only distinction is that the provider must accept your health plan and that you meet your plan’s coverage rules, such as getting prior authorization to see certain specialists or procedures.


If you are in the QMB program and are enrolled in Original Medicare only then you should not be billed when receiving a Medicare-covered service from any doctor. To protect yourself from improper billing, be aware that Original Medicare and Medicare Advantage providers who do not accept Medicaid must still comply with improper billing protections and cannot bill you. This often happens when your primary care physician sends you to a specialist who doesn’t take Medi-Cal. The specialist will attempt to bill you for the share of cost that Medi-Cal would be responsible for.


This is illegal and they cannot bill you for any amount over what Medicare has paid them. It is important to note that you keep your billing protections even when you receive care from Medicare providers in other states (Note: You can be billed if you are enrolled in a Medicare Advantage Plan and see an out-of-network provider, or if you have Original Medicare and see an opt-out provider).


Many physicians will have you sign a Patient Responsibility form that attempts to force you to accept all charges not covered by your insurance. You cannot choose to waive these protections and pay Medicare-cost sharing, and a provider cannot ask you to do this. So even if you have unknowingly signed one of these forms, it cannot legally remove those protections provided for you under the QMB program.

The doctors you see must accept the Medicare allowed payment and any QMB payment allowed as full payment for your care. Any doctor’s office that violates improper billing protections may be subject to penalties.


Who Can I Call?

If you feel that you have been improperly billed or have been sent to a collection agency, then you need to contact Medicare or your Medicare Advantage Plan (If you have one) and file a grievance. You can contact Medicare directly at 1-800-MEDICARE (1-800-633-4227).


Your Medicare Advantage Plan can be reached at the members service number on the back of your card. Both of these entities will be able to contact your doctor’s office or the collection agency and clear up any issues related to improper billing.


For more information on this program and other options available to you, please contact us to meet with a licensed professional who is eager to support you.


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