Preventing Improper Billing of Medicare-Medicaid Enrollees in Managed Care: Strategies for States and Dual Eligible Special Needs Plans

Integrated Care Resource Center Technical Assistance Brief
Publisher: Washington, DC: Centers for Medicare & Medicaid Services, Medicare-Medicaid Coordination Office
Feb 28, 2018
Claire Postman and James Verdier

Approaches to prevent improper billing include:

  • States can make capitated payments to D-SNPs for Medicare cost-sharing to enable seamless payment of cost-sharing to providers by the D-SNP. This allows D-SNPs to directly pay the provider for any cost-sharing amounts and eliminates the need for providers to submit separate cost-sharing claims to Medicaid because the D-SNP payment constitutes payment in full.
  • States can require D-SNP members to be enrolled in a Medicaid managed care plan offered by the same organization to facilitate the organization’s handling of cost-sharing payments to providers.
  • D-SNPs can include clear and prominent language on health plan provider portals, member identification cards, and Explanation of Payment documents (remittance advice notices) to enable providers to readily identify when no cost-sharing applies to the D-SNP member.
  • D-SNPs can create outreach materials and recurring trainings for providers to help them understand the billing prohibitions and identify which beneficiaries are protected from cost-sharing. 
Medicaid provides some degree of coverage for Medicare deductibles, copayments, and coinsurance amounts for about 85 percent of dually eligible beneficiaries. The vast majority of these Medicare-Medicaid enrollees are Qualified Medicare Beneficiaries and are protected from billing by any providers for unpaid Medicare cost-sharing. Although providers are prohibited from billing these protected beneficiaries for cost-sharing, improper billing continues to be an issue. The complexity of processing Medicare claims for cost-sharing, state policies concerning Medicare cost-sharing payments, and lack of provider awareness about billing prohibitions may contribute to the persistence of this issue. This brief explores strategies that states and Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) can use to streamline claims processing and communicate with providers and members in order to prevent instances of improper billing.