Doctors are improperly billing some on Medicare, U.S. says

Published July 31, 2016

WASHINGTON — Doctors are improperly billing poor people on Medicare for deductibles, copayments and other costs from which they are supposed to be exempt, the Obama administration says.

Federal officials have warned doctors that they may be subject to penalties if they persist in these practices. They could, for example, be fined or excluded from Medicare.

The people who are being billed improperly are "qualified Medicare beneficiaries" who are also enrolled in Medicaid. They are 65 and older or disabled and have low incomes, generally less than $1,010 a month for an individual or $1,355 for a married couple.

Federal law says that such beneficiaries do not have "any legal liability to make payment" to a doctor or a hospital beyond the amounts paid by Medicare and Medicaid. The Obama administration recently told doctors that they "must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a qualified Medicare beneficiary."

Despite this requirement, a study by the Department of Health and Human Services found that improper billing still appears to be "relatively commonplace" because "some Medicare providers unlawfully bill enrollees" after receiving payments from Medicare and Medicaid. Many low-income beneficiaries are unaware of the billing restrictions or are concerned about losing access to their doctors, so they "simply pay the cost-sharing amounts," the administration said. In other cases, it said, "unpaid bills are referred to collection agencies."

Tanya Kaltenbach, 45, of Evans, Ga., outside Augusta, is on Medicare because she is disabled. She said that one of her doctors, a specialist in rehabilitation and pain medicine, "has been adamant" that she pay about $25 for each visit — a total of hundreds of dollars over the past few years.

She showed the doctor's staff a Medicare publication stating that qualified Medicare beneficiaries are not subject to such charges, but the dispute continues. "I'm afraid that I'll be thrown out of the doctor's practice for making a fuss about copayments," said Kaltenbach, who said her income was less than $900 a month.

The Obama administration expressed its concerns in a report last summer, in a notice to health care providers in February, in a letter to insurance companies in April and again in the Federal Register two weeks ago.

Medicare, the insurance program for older Americans and disabled people, is run by the federal government. Medicaid, for low-income people of all ages, is financed jointly by the federal government and the states. Eligibility, benefits and provider payment rates vary from state to state.

About 7 million low-income people receive financial help through the program for qualified Medicare beneficiaries. State Medicaid agencies help pay Medicare premiums, deductibles, copayments and coinsurance. But states do not have to pay doctors the full amount of such costs.

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"Because of this gap in payment, many doctors and other health care providers try to bill the beneficiaries or refuse to provide services," said Denny Chan, a lawyer at Justice in Aging, a nonprofit legal advocacy group.