NSCLC: Protecting Medi-Cal Beneficiaries from Balance Billing: Resources for Advocates

From our colleagues at NSCLC (sign up for NSCLC newsletter here):

Advocates continue to report attempts by providers, particularly physicians, to ”balance bill” dual eligible beneficiaries (those who qualify for both Medicare and Medi-Cal)  for charges not covered by Medicare or Medi-Cal.  

Balance billing violates both federal and state law.  Providers may not balance bill any Medi-Cal patient who presents a Medi-Cal card.  In other words, a provider must accept as payment in full whatever amount the provider receives from Medicare, other insurance (if any), and Medi-Cal.  

The balance billing protection remains even if Medi-Cal pays nothing to the provider.  The only exception is that providers may bill Medi-Cal beneficiaries who have a monthly share of cost obligation, but only until that obligation is met for the applicable month.

If a provider bills a patient in error, the provider must stop immediately upon proof of Medi-Cal enrollment and must call off any collection efforts that have begun.  Upon receiving proof of Medi-Cal eligibility, debt collection agencies and/or providers also must correct any erroneous information sent to credit reporting agencies.  

Providers also are prohibited from asking a beneficiary to enter into a private pay agreement or otherwise waive balance billing protection.

Advocates who encounter balance billing issues may find that, in some cases, providers are genuinely confused about their obligations and unaware of procedures for processing crossover Medicare claims through Medi-Cal.  

The following resources can be helpful in addressing these situations:

Welfare and Institutions Code Section 14019.4 The state statute spells out balance billing protections clearly.

Physician’s Toolkit  A new resource prepared by the California Department of Health Care Services particularly around the Coordinated Care Initiative but containing explanations that apply to providers and advocates in non-CCI counties as well.  Look especially at “Physician services and payment under the CCI” and “FFS Medicare and the CCI”, both of which explain the prohibition and assist providers in understanding how they can properly process claims with Medi-Cal.

Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs)   A Centers for Medicare and Medicaid Services (CMS) pamphlet geared toward physicians describing federal prohibitions.

Crossover Only Provider Authorization Information   Advocates can direct providers to this page on the DHCS website where they can complete an abbreviated form in order to submit crossover claims to Medi-Cal without enrolling as full Medi-Cal providers.

If you are seeing balance billing issues for your clients, please let NSCLC know.  Contact Georgia Burke, gburke@nsclc.org.

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