First, what is Balance billing? When healthcare providers bill patients for charges that exceed the amount that Medicare reimburses for that service, or in other words, contractual write-offs. If the provider is participating in Medicare/ Medi-Cal balance billing, is illegal. Doctors that aren’t participating with Medicare, but they also haven’t opted out (non-participating) can balance bill you, but the total charge can’t be more than 15% than Medicare will pay. Providers that have opted-out cannot be reimbursed by Medicare. Chiropractors are the only providers that cannot Opt-Out of Medicare.
Federal law protects all Qualified Medicare Beneficiaries (QMB), California Law protects all Full Benefit Dual Eligible beneficiaries (FBDE). Federal regulations protect all FBDE’s in a Medicare Advantage plan against balance billing. Here is a list of those it protects regardless of how the beneficiaries receive their Medicare and Medi-Cal stated below.

• FBDE and QMB-only in Medicare
  Advantage
• FBDE and QMB-only in fee for service
  Medicare
• FBDE in Medi-cal managed care
• FBDE in fee for service Medi-Cal
• FBDE in Cal MediConnect
• FBDE who opt out of Cal MediConnect

Note ONCE a provider or debt collector for that provider obtains any proof of
Medi-Cal eligibility he/she can NOT seek payment from that beneficiary and must
cease all collections.

Here is an example table below of how Medicare and Medi-cal would pay a claim

• Billed charges $100
• Medicare allowed Amt and pays provider $80
• Medi-Cal allowed amt for office visit $70
• Medi-Cal pays provider $0

We know it can be confusing determining all the scenarios of balance billing.If you have questions or think you may be charging/ not charging someone in error give us a call.

Accurate Medical Billing & Audit