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