CMS Report Finds Widespread Illegal Billing of Low-Income Medicare Beneficiaries

“I don’t want to ‘rock the boat,’” explains a low-income Medicare beneficiary when asked about health services she receives illegal bills for. Despite her $329 a month income, this beneficiary pays $15.27 after every doctor’s appointment:

I know I should not be receiving these, but I don’t want to ‘rock the boat’. The doctor is in walking distance, so I don’t need to take public transportation. That saves me a lot because my income is only $329 a month. I ultimately do not know what I should and shouldn’t pay? I really feel anxious. I do not know what is going to happen with my health care. My food stamps were just cut. So you never know.

A new report from the federal Centers for Medicare and Medicaid Services (CMS) finds that many low-income Medicare beneficiaries are in the same situation. Afraid to rock the boat, they either are not receiving needed health care services or end up paying for services after being illegally billed.

Through a practice known as “balance billing,” health care providers are billing low-income Medicare beneficiaries for portions of their medical bills. Certain low-income Medicare beneficiaries, including those known as “Qualified Medicare Beneficiaries,” have legal protections that prohibit doctors from billing them for deductibles, co-payments, and co-insurance. Despite these protections, the report finds that lack of provider education, coupled with larger state payment system problems, is causing providers to illegally bill poor seniors.

The report confirms what we’ve heard from advocates in the field. That’s why we’ve been producing materials and conducting trainings to help advocates know when illegal balance billing practices are being used and what to do about it. See our presentation for advocates in California: California Balance Billing Protections: What Advocates need to Know

The new CMS report uses qualitative and quantitative data to tell the story of low-income Medicare beneficiaries and explain the multiple layers to the problem. CMS interviewed Medicare beneficiaries across the country to better understand the depth of illegal balance billing:

“I had a screening mammogram. I showed the girls at the office my card and they assured me they accept Medicare and Medicaid. Several months later, we got a Medicare summary that said my bill was submitted and paid. Then I got a bill from clinic that said my balance payment was $87.50. I showed my niece and she said not to pay because it is against the law. Then I got a statement that said everything was being turned over to collections. My niece said she will keep fighting for me.”

The report identifies multiple reasons behind the problem, ranging from the innocuous, such as doctors who are unaware of legal protections for QMB enrollees, to deliberate, such as such as doctors refusing to accept Medicare beneficiaries who are also enrolled in Medicaid. Employing utilization data, the quantitative portion of the report documents the causal connection between low Medicaid reimbursement rates and poorer access to health care for low income beneficiaries compared to others in the Medicare system.

The CMS study verifies alarming trends Justice in Aging has long identified as problems for low-income Medicare beneficiaries:

  • Doctors are balancing billing low-income Medicare beneficiaries
  • Low-income Medicare beneficiaries find the billing process confusing and complex
  • Low-income Medicare beneficiaries face insufficient coverage for needed services.

About Duals Team

The Justice in Aging Duals Team is Amber Cutler, Georgia Burke, Fay Gordon, and Denny Chan.