Balance billing and what it means for you
June 1, 2019
Balance billing is when a provider bills you for the difference between the amount he charges for a product or service and the insurance company’s negotiated amount. For example, if the provider’s charge is $100 and the allowed amount or the amount the insurance will cover is $70, the provider may bill you for the remaining $30. This amount can include deductibles, co-insurance and copayments.
There are certain Medicare beneficiaries who providers are not allowed to balance bill. This is also referred to as improper billing. Once you have enrolled in Medicare, whether due to turning 65, having received 24 months of Social Security Disability benefits or having been diagnosed with End Stage Renal Disease at any age, you are able apply for the Medicare Savings Programs of which there are four. The programs are designed to provide financial relief for those who are of limited income and assets and meet the other application criteria. Medicare beneficiaries who qualify for the Medicare Savings Program known as Qualified Medicare Beneficiary (QMB) cannot be balance billed. To qualify for the QMB program your income must not exceed 100% of the federal poverty level for 2019, which for single individuals in Alaska is $1,300 per month and for couples is $1,761 per month.
Additionally, your assets cannot exceed $7,560 for single individuals and $11,340 for couples. Counted assets do not include the home you live in, your primary vehicle, and a $20 per month set-aside. However, bank accounts and investment accounts are considered.
If you qualify for the QMB program, there are several benefits, one of which is that Medicare providers are not allowed to bill you for any part of the medically necessary, Medicare-covered services and/or products that you receive. Other benefits of the QMB program are that if you are an individual who does not have 40 credits accrued with Social Security — which equals 10 years of work history — and therefore have to pay for Medicare Part A (hospital insurance), the QMB program will pay that premium for you and also your Medicare Part B (medical insurance) premium.
Medicare beneficiaries may be screened and provided with the application for these programs by contacting the Alaska Adult Public Assistance offices or by contacting the Medicare Information Office at 1-800-478-6065.
It is important to understand balance billing so that you are not overcharged for your medical services and products. Even providers who do not accept Medicaid must comply with the balance billing rules.
How can you tell if you are being improperly billed? There are multiple ways of checking. First, check your Medicare Summary Notice (MSN) – the quarterly statement you receive from your Medicare Administrative Contractor (MAC) that explains your processed claims. For Alaskans, the MAC is Noridian Healthcare Solutions. You should receive an MSN every three months if you have received services during that time. Your MSN should have a statement on page one with a notice explaining your QMB status and stating that providers and suppliers who accept Medicare aren’t allowed to bill you for any additional amount.
You can also access your claim information in an expedited manner by establishing a mymedicare.gov account. Noridian will post the claim information within 24 hours of processing. Your QMB status is also shown on the Remittance Advice document that providers receive from Noridian explaining how each claim was processed. This document will show the protection from improper billing that QMBs enjoy. It will additionally show zero liability for co-pays and deductibles.
If you are participating in the QMB program you should let your provider know. If you are being improperly billed, you should contact the provider immediately and notify them that you are in the QMB program and cannot be charged for Medicare deductibles, coinsurance, and copayments. If you have already made payment on a bill, you should request a refund. It is important to note that you cannot choose to waive these protections and providers cannot ask you to do this.
If a provider does not stop balance billing after your request, you can report your dilemma to the Medicare Information Office at 1-800-478-6065 or call 1-800-Medicare. Medicare can confirm your status in the QMB program, request your provider stop the improper billing and request they reimburse any payments that have been made.
Be sure to make the most of your QMB status and save yourself from any improper costs for your medical care.
Nila Morgan is a Certified Medicare Counselor who works at the Anchorage Senior Activity Center.