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DPW'S MA BULLETIN ON QMB PAYMENTS
SEPTEMBER 1, 1998 DEADLINE FOR FILING FOR PAYMENT
DATE: August 5, 1998
ANY QUESTIONS RELATED TO THE BULLETIN CAN BE FAXED to 717-233-4103 OR E-MAILED to BruceB@capozziassociates.com.
AS PART OF THE SETTLEMENT OF THE PHCA CLASS ACTION, DPW HAS ISSUED MA BULLETIN NOS. 35-98-10/36-98-10 - "MEDICARE COST-SHARING PAYMENTS FOR NURSING HOME RESIDENTS". THIS BULLETIN ADVISES PROVIDERS ABOUT:
(1) HOW TO OBTAIN QMB-RELATED MEDICARE COST SHARING
PAYMENTS FOR 1996-1997 SERVICES
(2) LIMITS ON BILLING FOR QMB-RELATED AND ALL OTHER
MEDICARE COST SHARING FOR PERIODS AFTER 1997
(3) CONDITIONS TO OBTAIN PAYMENT FOR 1996-1997 COST
SHARING PAYMENTS
NOTE THAT PROVIDERS SEEKING QMB-RELATED COST SHARING PAYMENTS FROM DPW ARE REQUIRED TO FILE THE "CERTIFICATION AND AGREEMENT FORM" INCLUDED IN THE BULLETIN ON OR BEFORE SEPTEMBER 1, 1998. THE FORM ALSO REQUIRES PROVIDERS TO "AGREE" TO THE FOLLOWING:
THAT DPW'S PAYMENTS ARE SUBJECT TO THE REQUIREMENTS AND CONDITIONS STATED IN THE MA BULLETIN.
THAT, FOR THE 1996-1997 COST SHARING PAYMENTS FOR SERVICES PROVIDED TO NON-QMB RESIDENTS, THE PROVIDER MAY ONLY BILL MEDICARE BAD DEBT AS TO ANY UNPAID AMOUNT.
THAT, FOR THE 1996-1997 COST SHARING PAYMENTS FOR SERVICES PROVIDED TO QMB RESIDENTS WHICH MAY HAVE BEEN BILLED THROUGH THE PATIENT PAY AMOUNT, THE PROVIDER WILL REPAY DPW NO LATER THAN FEBRUARY 15, 1999 FOR ANY AMOUNT THAT HAS BEEN PAID OR "THAT WILL BE PAID" BY DPW UNDER THE QMB PAYMENT PROCESS.
THAT ANY DISPUTES RELATING TO PROVIDER CLAIMS TO DPW FOR PAYMENT OF MEDICARE COST SHARING AMOUNTS FOR 1996-1997, INCLUDING DISPUTES RELATING TO DENIALS OF INVOICES, SHALL BE LITIGATED EXCLUSIVELY IN DPW'S BUREAU OF HEARINGS & APPEALS.
THE FORM DOES NOT REQUIRE PROVIDERS TO "AGREE" TO OTHER POINTS INCLUDED IN OTHER PARAGRAPHS, ONLY TO ACKNOWLEDGE THAT THEY "UNDERSTAND" STATEMENTS CONCERNING APPLICABLE REGULATIONS, INCLUDING THAT 55 PA. CODE § 1187.102 "PROHIBITS" PROVIDERS FROM SEEKING OR ACCEPTING PAYMENT FOR UNCOLLECTED COST SHARING AFTER 1997 EXCEPT THROUGH THE MEDICARE BAD DEBT PROCESS.
SOME POINTS ABOUT THE BULLETIN
1. Providers May Opt Out of the Bulletin Payment Process Simply
By Not Filing a Certification and Agreement Form. Providers may want to Opt Out if they have already been paid through the patient pay process.
The Bulletin provides that DPW will not process and pay a facility's cost sharing claims unless it receives a Form on or before September 1, 1998. If a provider has already received payment for cost sharing amounts throught the patient pay process, they can avoid obtaining duplicate payments simply by not filing the Form. The Bulletin indicates that if DPW makes payment in error to a facility that did not file a Form, it will recoup payments made in error at a later time.
2. Providers who have been paid for QMB-related expenses by Medicare may also want to Opt Out, but should repay Medicare for QMB-related bad debt expenses received for services in 1996-1997 which could have been collected from DPW, pursuant to HIM-15, § 316. Pursuant to 42 U.S.C. § 1320a-7b(a)(3), concealment or failure to disclose a known event affecting the initial or continued right to payment under a Federal health care program is a felony.
3. Providers Who Opt In and Seek Payments from DPW Must Keep to
DPW's Schedule:
(a) On or before September 1, 1998 - FILE ACCEPTANCE FORM
(b) September 1998 - DPW Conducts Special Cycle
(c) October 1, 1998 through December 15, 1998:
(i) Providers review DPW Special Cycle Results
(ii) Providers determine services not paid by DPW in Special Cycle which are due from DPW
(iii) Providers prepare and submit MA309C for Part A services not paid in Special Cycle
(iv) Providers prepare and submit MA319C for Part B services not paid in Special Cycle
(d) November 16, 1998 - Deadline to submit special exception MA319C's for cost sharing for Part B services provided during January-March, 1998.
(e) 60-days after RA rejecting any MA309C or MA319C for 1996-1997 cost sharing amounts - DEADLINE TO RESUBMIT
ONE CLAIM ADJUSTMENT/RESUBMISSION.
(f) FEBRUARY 15, 1999 - DEADLINE FOR PROVIDERS TO REPAY DPW FOR ANY OVERPAYMENTS DUE TO BEING PAID BOTH BY COST-SHARING PAYMENT PROCESS AND THROUGH PATIENT PAY AMOUNTS.
4. Providers Who Opt In MUST:
(a) File Acceptance Form by September 1, 1998.
(b) Repay Medicare for QMB-related Bad Debt Expense allowed at audit, but paid by DPW through process (HIM-15, § 316).
(c) Repay DPW for Cost Sharing collected through patient pay process and related to services in 1996-1997 and not seek payment for such cost sharing through the process for services provided during 1996-1997.
5. ARE PROVIDERS WHO OPT IN PRECLUDED BY THE
ACCEPTANCE FORM FROM COLLECTING COST SHARING DUE FROM NON-QMB RESIDENTS FROM PATIENT PAY AMOUNTS FOR SERVICES ON OR AFTER JANUARY 1, 1998?
NO. While the Acceptance Form requires providers to acknowledge
that they understand that 55 Pa. Code § 1187.102 prohibits seeking payment except through the Medicare Bad Debt process, it does not require them to "agree" to that prohibition and preserves their rights to challenge DPW's implementation of its cost-sharing obligations for dual eligibles after 1997. The Acceptance Form does not waive providers' rights to rely on the holding in Pennsylvania Medical Society v. Snider, 29 F.3d 886 (3rd Cir. 1994), that DPW is precluded by the Medicare Act from limiting by regulation a provider's rights to seek recovery of cost sharing from a resident.
Note that the Balanced Budget Act of 1997 does preclude a provider from seeking such payment from a QMB-eligible resident (BBA § 4714; P.L. 105-33, § 4711(a and b)).
6. ARE PROVIDERS WHO OPT IN PRECLUDED FROM OBTAINING MEDICARE BAD DEBT PAYMENTS FOR SERVICES TO MA ELIGIBLE RESIDENTS FOR UNCOLLECTED COST SHARING RELATED TO SERVICES ON OR AFTER JANUARY 1, 1998?
NO. THE BULLETIN EXPRESSLY ACKNOWLEDGES THIS.