Improper billing (also sometimes referred to as "balance billing") occurs when doctors, hospitals, or other providers charge beneficiaries with both Medicaid and Medicare for co-pays, co-insurance, or deductibles.

Patients who have both Medicaid and Medicare (including Medicare Advantage) should never be charged for services covered under Medicaid or Medicare. Billing for covered services is illegal under both federal and state law.

As more and more dual eligible patients move to managed care plans, improper and illegal billing may increase due to doctor & hospital confusion. Justice in Aging wants to make sure patients are protected. In 2011 we authored a policy paper on the need to improve protections for dual eligibles, Improving the Qualified Medicare Benefit for Dual Eligibles. In early 2017 we released a new issue brief, Fighting Improper Billing of Dual Eligibles: New Strategies and created a toolkit to provide advocates with resources to help their clients who are being improperly billed. See our toolkit of resources in the tabbed sections below.

Advocate Alert

• Improvements in Medicare Summary Notices for QMBs 

Chart

• State-specific Improper Billing Authorities
• Summary of Administrative Changes for QMB Improper Billing

Fact Sheet

• Summary of CMS Administrative Changes for QMB Improper Billing
• What Should California Advocates Do if Their Clients are Improperly Billed?

FAQ

• Low Income Subsidy (“Extra Help”) for Dual Eligibles Receiving Home and Community-Based Services

Issue Brief

• Advance Beneficiary Notices, Administrative Fees, and Dual Eligibles
• Fighting Improper Billing of Dual Eligibles: New Strategies
• QMB Identification Practices: A Survey of State Practices
• Qualified Medicare Beneficiary (QMB) Protections in Medicare Advantage: Issues, Tips and Avenues for Advocacy

Aging Today Article

• Efforts Take Root to End Illegal Billing of Low-Income Medicaid Recipients

Trainings

• The Qualified Medicare Beneficiary (QMB) Program—An Update for Advocates: Part 2 of 2 - July 24, 2019
• The Qualified Medicare Beneficiary (QMB) Program—An Update for Advocates: Part 1 of 2 - July 23, 2019
• Improvements to the Qualified Medicare Beneficiary Program (QMB) - Part 2 - September 25, 2018
• Improvements to the Qualified Medicare Beneficiary Program (QMB) - Part 1 - September 24, 2018
• California Balance Billing Protections: What Advocates Need to Know - July 25, 2018
• Breakthrough Changes in Improper Billing - October 2, 2017
• Protecting Dual Eligibles from Balance Billing - February 23, 2016
• Protecting Dual Eligibles from Balance Billing: What Advocates Need to Know - February 23, 2016

Model Letters

• Overview of Model Letters to Providers-National
• Model Improper Billing Letter No. 1 (Client with Original Medicare and QMB+)
• Model Improper Billing Letter No. 2 (Client with Original Medicare and QMB-only)
• Model Improper Billing Letter No. 3 (Client with Medicare Advantage and QMB+)
• Model Improper Billing Letter No. 4 (Client with Medicare Advantage and QMB-only)
• Model CA Improper Billing Letter No. 1 (Client with Original Medicare and QMB+)
• Model CA Improper Billing Letter No. 2 (Client with Original Medicare and QMB-only)
• Model CA Improper Billing Letter No. 3 (Client with Medicare Advantage and Medi-Cal or Cal Medi-Connect)

CMS Documents

• What to Do if You're Wrongfully Billed (in English)
• What to Do if You're Wrongfully Billed (in Spanish)
• Three Tips for QMBs Dealing with Wrongful Billing (in Spanish)
• Medicare-Medicaid General Information-Billing
• Blog Post: CMS Report Finds Widespread Illegal Billing of Low Income Medicare Beneficiaries
• Call Letter: Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing
• Medicare Learning Network Notice: Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program
• Medicare Learning Network Notice: Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMBs) for Medicare Cost-Sharing

Consumer Resources

• What To Do if a Provider Bills you Improperly (English)
• What To Do if a Provider Bills you Improperly (Spanish)
• What To Do if a Provider Bills you Improperly (Chinese)
• What To Do if a Provider Bills you Improperly (Korean)
• What To Do if a Provider Bills you Improperly (Russian)

Share Your Improper Billing Story

Have you worked with a low-income senior or dual eligible whose provider has improperly billed them for medical services?  Please help our advocacy efforts. Take a few minutes to complete this brief questionnaire to share your client’s story of improper billing with us. Justice in Aging will collect these stories and use systemic issues we see in the stories to inform our advocacy with federal and state officials, as well as other stakeholders. Help us stop the persistent practice of improper billing by sharing your client’s story. All information will be kept confidential. Share today! If you have any questions about improper billing of dual eligibles or need technical assistance, contact us.