Medical Billing Forum
Billing => Billing => : Trisha April 15, 2010, 12:30:02 AM
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because MDCR does not cover bathroom items like a shower chair, and the patient has medicaide (MQMB) do I still bill MDCR first and get a denial then bill TMHP or do I skip MDCR and bill directly to TMHP.
Thanks for any help given. :)
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r u from NC? this is the only state that I know has qMB medicaid. You do know it only pays for the medicare part B premiums, therefore there is no coverage for anything else.
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In NY, if there is a service not covered by Medicare but it is covered by Medicaid it can be billed directly to Medicaid with a code indicating non medicare covered service. It is not necessary to bill Medicare. But you need to check with your state's Medicaid.
Michele
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I think this site might be helpful. QMB, SLMB and QI are all federal programs that states can enhance with their own provisions attached. Again - states can increase the coverage - not decrease.
Where I work - I am in PA - if we are contracted with Medicare and the patient has Medicare, they are billed and once denial is received, we submit to the next carrier. Be it medicaid or not with the Medicare denial. We do Medicare first and Medicaid second. I always find I get the right answer by just calling Medicaid. Hope this helps.
http://webcache.googleusercontent.com/search?q=cache:5SAQrRL5NGgJ:www.mymedicarecommunity.org/attachment.php%3Fattachmentid%3D303%26d%3D1245782178+do+you+bill+medicare+first+or+qmb&cd=2&hl=en&ct=clnk&gl=us
http://www.medicareadvocacy.org/InfoByTopic/MedicareSavingsPrograms/MedicareSavingsProgsMain.htm
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Yes then again like i said if it is QMB its NOT MEDICAID, as traditional..no coverage. It just pays the Medicare premiums..therefore patient is SELF PAY!!
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No arguement from me. ;D I agree it is not a Medicaid plan. It does however pay more then just the patient's premiums for Medicare.
QMB (Qualified Medicare Beneficiary Program)
The QMB program provides the following benefits:
•Payment of Medicare Part A monthly premiums (when applicable).
•Payment of Medicare Part B monthly premiums and annual deductible.
•Payment of co-insurance and deductible amounts for services covered under both Medicare Parts A and B.
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there is a clause to that paying the deductibles. so in 99.9% of the cases. QMB won't pay. We get them all the time
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I was not aware of this clause so I did some research with CMS. I found this information on explaining all the rules and when what applies. Very interesting. I plan to keep a copy for myself, for future use.
Hope his helps.
http://www.cms.gov/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf
Pay_My_Claims,
I have appreciated all your advice and want you to know that I in no way want to be confrontational. In no way! I value your guidance. I know that these types of plans are very tricky and spent some time working with them. In the link above there is a section that I think is important for people to know. Learning is dynamic, there is something new to learn each day either because of invention, discovery or changes.
Balance Billing a QMB
For a QMB, Medicaid is responsible for deductible,
coinsurance, and copayment amounts for Medicare
Part A and B covered services. Providers may not bill
a QMB for either the balance of the Medicare rate
or the provider’s customary charges for Part A or B
services. The QMB is protected from liability for Part
A and B charges, even when the amounts the provider
receives from Medicare and Medicaid are less than the
Medicare rate or less than the provider’s customary
charges as specified in the Balanced Budget Act of
1997 (BBA). Providers who bill a QMB for amounts
above the Medicare and Medicaid payments (even
when Medicaid pays nothing) are subject to sanctions.
Providers may not accept QMB patients as “private
pay” in order to bill the patient directly and providers
must accept Medicare assignment for all Medicaid
patients, including a QMB.
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Pay_My_Claims
Sorry, I should have looked at the NC Health and Human Services. I found some information there and I see now what plan you were talking about earlier.
:o
Medicare-Aid
Medicare-Aid is a free Medicaid program for people who have Medicare and also have limited income and resources. The program can help pay your Medicare premiums, co-payments and deductibles. It is also known as Medicare Savings Program. There are three different levels of Medicare-Aid. All are based on an individual’s countable income.
Comprehensive Medicare-Aid (MQB-Q) covers:
1.Medicare Part B premium
2.Medicare Part A premiums (when applicable)
3.Medicare hospital deductible
4.Medicare annual deductible
5.20% Medicare co-payment
6.If you go into a nursing home, Medicare-Aid only covers the first 20 days. For more information, see Medicaid for long term care.
Limited Medicare-Aid (MQB-B) covers the Medicare Part B premium
Limited Medicare-Aid Capped Enrollment (MQB-E) also covers the Medicare Part B premium. Funds for this program may be limited.
Medicare-Aid Monthly Income Limits (Effective 04/2009) Program Number in Family
1 2
MQB-Q $903 $1,215
MQB-B $1,083 $1,457
MQB-E $1,219 $1,640
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I was not aware of this clause so I did some research with CMS. I found this information on explaining all the rules and when what applies. Very interesting. I plan to keep a copy for myself, for future use.
Hope his helps.
http://www.cms.gov/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf
Pay_My_Claims,
I have appreciated all your advice and want you to know that I in no way want to be confrontational. In no way! I value your guidance. I know that these types of plans are very tricky and spent some time working with them. In the link above there is a section that I think is important for people to know. Learning is dynamic, there is something new to learn each day either because of invention, discovery or changes.
Balance Billing a QMB
For a QMB, Medicaid is responsible for deductible,
coinsurance, and copayment amounts for Medicare
Part A and B covered services. Providers may not bill
a QMB for either the balance of the Medicare rate
or the provider’s customary charges for Part A or B
services. The QMB is protected from liability for Part
A and B charges, even when the amounts the provider
receives from Medicare and Medicaid are less than the
Medicare rate or less than the provider’s customary
charges as specified in the Balanced Budget Act of
1997 (BBA). Providers who bill a QMB for amounts
above the Medicare and Medicaid payments (even
when Medicaid pays nothing) are subject to sanctions.
Providers may not accept QMB patients as “private
pay” in order to bill the patient directly and providers
must accept Medicare assignment for all Medicaid
patients, including a QMB.
Hey BLK, I didn't know it was confrontational. I didn't take it that way at all. Its hard to determine "tone" in an email, but its all good!!
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LOL! I did not mean you being confrontational. I was afraid you would think that 'I' was being confrontational.
You are right, texing, emails and forums are great but you can't read the tone and body language.
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lol, its all good, I can be uh, how you say it "opinionated* :-) I love a good debate, but I can be a bit much at times!!
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blhoffman - I want to hire you to do research! You really delve into things.
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and that is the key to medical billing.....research. Most questions can be answered that way.
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Thank you for all the help it is greatly appreciated! In TX there is QMB-covers deductibles and coinsurances only, the pt does not have regular medicaid benifits. MQMB- covers deductibles, coinsurances and the pt has medicaid benefits which through my research my understanding was that if MDCR did not cover an item like bathroom DME that the medicaid would pay. Then I got a curve ball, a denial because the pt only has traditional medicaid (how is that different)?
Thanks :D
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FOR NC, if the patient has QMB medicaid, it won't cover anything that wasn't covered by medicare. if they have traditional, we would just bill medicaid directly. you not supposed to bill them just for a denial. (medicare)
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This is the newest information I could locate on TX medicaid for bathroom DME. There is a tab at the bottom for codes not covered. I'm not sure what code you billed. Not sure it helps. ???
http://www.tmhp.com/File%20Library/File%20Library/Medicaid/58799_BathBed.xls
http://www.tmhp.com/txtlstvw.aspx?LstID=289434c6-ef74-4a64-89b0-bf74614c4ec8