By now, everyone should know what a QMB patient is. This is a patient who is a qualified Medicare beneficiary. If someone is classified as a QMB patient, this means they have been deemed to be a patient of modest means and therefore it is illegal to collect any monies from these patients. This means the Podiatrist can not collect any co-payments or deductibles. The monthly limits are 1,025 per month income for individual or 1,374 per couple.

A patient may be a QMB patient with Traditional Medicare, however, they may be a QMB while in an HMO.

The QMB patient is a catastrophe for the Podiatrist. There are many instances where you will be treating patients for free.

Let us review why.

Mrs. Smith came to your office Jan 1st 2018. She presents for an infected ingrown toenail and you opt to perform a partial nail avulsion under local anesthesia.
CPT code: 11730
Let’s say this code reimbursed at 100 dollars for arguments sake.
The deductible is 183 dollars.

This means Medicare does not pay you anything. You can’t bill the patient because they have protection from payment collection under QMB status.

You just saw the patient for free but helped them meet 100 dollars of the 183 deductible.

You used a syringe, local anesthesia and bandage material, and 15-20 minutes of your time.

So, you actually lose money.

Is this fair?
Can you name one profession that is being told to perform their job for free?
You accept liability for free. Fair? I opine not fair.

Same Example of Mrs. Smith but now let’s put her in an HMO. We will call it HMO x.
Many of these patients may have 40-50 dollar copayment but your never allowed to collect them.

They call this “cost sharing”. What that translates into is: thievary. Podiatrists are being robbed of hard earned work.

No one discusses this. I don’t understand why not. It is costing Podiatry offices thousands of dollars.

I am not sure of other states so I will speak for NY. MD’s are treated differently. They are allowed to turn around and bill Medicaid for the copay and deductible and get reimbursed 80 percent of the allowed amount. That’s a lot better than zero.

What is Podiatry doing about it?
If anyone has an answer please let me in on it.

  • Comments (3)
  • Once again, as I've stated [read: complained about] before, in other threads along the lines of this very heated topic:  In Texas, since January 1st of 2012, a provider may not collect from Texas MediCaid the balance (nor fee), via cross-claims process, any amount NOT paid by Medicare; and, this includes in instances of when MediCare paid zero.  It was, in fact, illegal for the state to do so; and, in effect 'they' (i.e., Texas MediCaid payors) were breaking the very laws supporting Medicare and Medicaid "cross-over claims."  However, this was rectified a few years or so later, I forget the date, but I read it as such, when the Texas state legislature made it legal; and continue to do so, to my knowledge, to the present day.  In other words, in Texas, MediCaid does NOT pay 'against' that which Texas MediCare did not, or does not, pay; so, you/we LOSE all around when it comes to patients on MMP's(*).  *MMP = Medicare - Medicaid Plans. 

  • Thank you for this information. It is interesting that NYSPMA informed members over and over how one can not bill the patient for deductibles and coinsurance but I never saw any information on who will pay for this part of the service.
    I will look into this further.
  • Thank you Jeff for bringing up this blog.

    The following are my personal opinions:

    A QMB patient that qualifies for home care is enrolled in a managed Medicaid program with a “podiatry benefit”. What this podiatry benefit does is cause additional paperwork and denials for podiatrists. NYS Medicaid transferred their responsibility to pay for

    1. the deductible of $180 and or
    2. 85% of a managed medicare programs co payment 

    to the Medicaid managed care program that has a “podiatry benefit”.  In order for a podiatrist to get paid, a copy of the explanation of benefits must be mailed with a manual paper bill to the managed Medicaid program and one must call such a program to get the mailing address. Getting this information does take some time and effort. 

    If the managed Medicaid program denies payment, then one can consider complaining to the New York Dept of Health section that licenses that insurance company and or the office of Medicaid inspector general at 518 473-3782. 

           3. According to HIPPA guidelines claims should be uniformly processed. If a situation is set up by having the managed Medicaid program insist on paper bills and paper copies of the EOMB this just might not be in compliance with such Federal guidelines. 

           4. Every managed medicaid program I know of has some sort of podiatry benefit. Has anyone ever seen any QMB that is not enrolled in managed medicaid program or enrolled in a managed medicaid program without a podiatry benefit?