MENU Close
Close
  • Home
  • Services
  • Attorneys
  • Resources
  • News & Events
  • About Us
  • Contact Us
  • Join our Team
Search
Back
    Quick Links:
    Join Webinar
    Read News
    Our Location
    A
    Alternative Dispute ResolutionAntitrust & Trade RegulationAppellate Practice
    B
    Banking & Financial ServicesBankruptcy, Creditors’ Rights, and Financial RestructuringBeer LawBusiness Law
    C
    Cannabis LawConstruction LawCriminal Defense
    E
    Economic Development LawElder Care & Special Needs LawElectronic Discovery ("E-Discovery")Environmental LawEstate Planning and Administration & Wealth PreservationExecutive Compensation, Employment, ERISA, and Employee Benefits
    F
    Food, Beverage & HospitalityFranchise Law
    H
    Health Care & Life SciencesHealth Care ProvidersHigher EducationHospitals and Health Networks
    I
    ImmigrationInsurance CoverageIntellectual PropertyIntellectual Property Litigation, Arbitration, and Dispute ResolutionIntellectual Property Portfolio Strategy, Management & LicensingInternational BusinessInternet Law
    L
    Labor & EmploymentLiquor Law, Licensing, Manufacturing, and DistributionLitigation
    M
    Media LawMergers & AcquisitionsMunicipal Law
    N
    Non-Profit Law
    P
    Patent Preparation and ProsecutionPharmaceutical / Medical Devices / Pharma ServicesProducts and Consumer Liability DefenseProfessional LiabilityPublic Utilities
    R
    Real Estate, Finance, and Land Use
    S
    SecuritiesSolar Energy
    T
    TaxationTelecommunicationsTrademark & Copyright Protection & Enforcement
    V
    Venture Tech & Emerging Growth Companies
    W
    White Collar Investigations & DefenseWorkers’ Compensation
    • New Jersey
    • New York
    • Pennsylvania
    • Blogs
    • Articles
    • Podcasts
    • COVID-19 Resources
    • News
    • Events
    • Webinars
    • About Us
    • Delivering Value
    • Diversity & Inclusion
    • Meritas

    New Jersey

    400 Crossing Boulevard
    8th Floor
    Bridgewater, NJ 08807
    Phone:(908) 722-0700
    Fax:(908) 722-0755

    28 Valley Road
    Suite 1
    Montclair, NJ 07042

    New York

    7 Times Square
    21st Floor
    New York City, NY 10036
    Phone:(212) 808-0700
    Fax:(212) 808-0844

    Pennsylvania

    515 West Hamilton Street
    Suite 502
    Allentown, PA 18101
    Phone:(610) 391-1800
    Fax:(610) 391-1805

    • What sets us apart
    • Attorneys
    • Other Professionals
    • Professional Development
    • Non-Discrimination Policy

    Categories

    Hospitals and Health Systems - Audits and Reimbursement Hospitals and Health Systems - Consent and Treatment Hospitals and Health Systems - Corporate and Governance Hospitals and Health Systems - Corporate Compliance Hospitals and Health Systems - Fraud and Abuse Hospitals and Health Systems - Government Investigations Hospitals and Health Systems - Health Records Hospitals and Health Systems - HIPAA and HITECH Hospitals and Health Systems - Managed Care Hospitals and Health Systems - Medical Staff Issues Hospitals and Health Systems - Medical Training Programs Hospitals and Health Systems - Medicare Hospitals and Health Systems - Mergers, Affiliations and Joint Ventures Hospitals and Health Systems - Peer Review Hospitals and Health Systems - Professional Services Agreements Pharmaceutical Industry - Agreements with Physicians Pharmaceutical Industry - Regulatory Compliance Physicians and Providers - Audits and Reimbursement Physicians and Providers - Certifications Physicians and Providers - Credentialing Physicians and Providers - Disciplinary Actions Physicians and Providers - Employment Agreements Physicians and Providers - Fraud and Abuse Physicians and Providers - Government Investigations Physicians and Providers - HIPAA and Privacy Physicians and Providers - Impairment Physicians and Providers - Licensing Physicians and Providers - Litigation Physicians and Providers - Medicare Physicians and Providers - Peer Review Physicians and Providers - Practice Acquisitions Physicians and Providers - Practice Issues Physicians and Providers - Regulatory Compliance Physicians and Providers - Supervision Physicians and Providers - Training Uncategorized
    Blogs > The Legal Diagnosis > Billing Pennsylvania Medicaid for Nursing...
    Member
    F. Peter Lehr
    Visit Profile

    Billing Pennsylvania Medicaid for Nursing Facility Residents’ Medicare Part B Copays Ruled as Impermissible Balance Billing

    Billing Pennsylvania Medicaid for Nursing Facility Residents’ Medicare Part B Copays Ruled as Impermissible Balance Billing

    The Pennsylvania Commonwealth Court has upheld an order of the Department of Human Services (“DHS”) disallowing a nursing facility’s practice of billing Medicaid for Medicare cost-sharing amounts of dual eligible (Medicare and Medicaid) residents.  See Mulberry Square Elder Care v. D.H.S., No. 371 C.D. 2017 (Decided:  July 26, 2018).  The Court found that by representing Medicare Part B copays as costs incurred, the nursing facility held residents legally liable for their payment without collecting the amount, and therefore, engaged in prohibited balance billing.

    At issue was a billing practice instituted by a nursing facility by which it attempted to recoup unpaid Medicare Part B copays of its residents by deducting the amount of the copays from the patient liability amounts, as it is permitted to do in certain circumstances for “other medical expenses” (i.e., the costs of medical goods or services incurred during that month).  Then, the nursing facility billed Medicaid for the Part B copays as “other medical expenses” in order to offset the amount subtracted from the patient liability.  In so doing, the facility sought and was paid more than the maximum Medicaid fee for the service. Under federal and state law, Medicaid is prohibited from paying Medicare cost-sharing amounts, such as copays, when the Medicare payment for the service exceeds the Medicaid payment.

    As part of a billing audit, DHS disallowed the facility’s billing practice based on incorrect patient liability amounts, and for billing Medicare Part B copays as “other medical expenses.”  On appeal, the facility argued DHS had no basis for taking such action as it did not promulgate a regulation prohibiting the billing practice.  DHS countered by noting that the billing practice directly violated federal and state law.  It also asserted that by holding residents liable for the copays by deducting the amount from their patient liability and billing them as “other medical expenses,” the facility engaged in prohibited balance billing.  Balance billing involves holding patients liable for charges that remain unpaid by Medicare or Medicaid.  The Court ruled in favor of DHS’ position and found that the facility engaged in impermissible balance billing, even though it only billed, and did not collect, amounts from residents.

    The Commonwealth Court’s decision in Mulberry serves to remind nursing facilities and other providers to be compliant in holding enrollees of the Medicare program responsible for any cost-sharing amounts, such as copays, and to be mindful of the general prohibition on balance billing.

    If you have any questions about this post or any related matters, please contact me at plehr@norris-law.com.

    Member
    F. Peter Lehr
    Visit Profile

    Related Posts

    Coronavirus Alert: Historic Expansion of Telehealth in Response to COVID-19 Crisis OIG to Waive Sanctions for Providers’ Waiver of Telehealth Cost-Sharing Amounts During Coronavirus (COVID-19) Public Health Emergency Medicare Revocation of Enrollment – CMS Continues to Needlessly Punish Physicians

    Share

    Tags

    #balance billing #copays #cost-sharing #Department of Human Services #DHS #Medicaid #medical expenses #medicare #Mulberry #nursing facility

    Similar Posts

    June 7, 2021
    Fighting HMO and Insurance Company Terminations
    Fighting HMO and Insurance Company Terminations
    May 4, 2020
    New Provider Relief Fund Application Portal Now Open
    New Provider Relief Fund Application Portal Now Open
    April 25, 2018
    New York State - OMIG Releases its Work Plan for the 2018/2019 Fiscal Year
    New York State - OMIG Releases its Work Plan for the 2018/2019 Fiscal Year

    Helpful links

    • About Us
    • News
    • Services
    • Blogs
    • Attorneys
    • Articles
    • (COVID-19)
    • Events
    • Join our Team
    Connect

    Connect with Us

    • LinkedIn
    • Facebook
    • Twitter
    • Instagram
    • Youtube

    Join our growing team

    We are looking for quality attorneys to help us do more for our clients. At Norris McLaughlin, each attorney has the same opportunity to succeed whether you’re at the beginning of a career or pinnacle of the profession.

    Learn More

    Subscribe to our content

    Receive timely legal information delivered to your inbox

    This field is for validation purposes and should be left unchanged.
    © , Norris McLaughlin, P.A., All Rights Reserved. Attorney Advertising.
    VIEW OUR DISCLAIMER,  TERMS OF USE,  AND PRIVACY POLICY

    We use cookies to ensure that we give you the best experience on our website. If you continue to use this site we will assume you consent to our cookie policy. Learn more