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At times, medical billing may already seem like something of a byzantine process. Between various insurers having differing protocols and various portions of each procedure being covered by patients and insurers and various state and federal guidelines that must be met, it can all become hugely overwhelming. As if medical billing were not complicated enough on its own, there are also variations in how government programs such as Medicare and Medicaid are handled. Here are three differences in the ways Medicare vs Medicaid billing have to be handled. 

Qualification Criteria

Medicare is a federal program that works in conjunction with Social Security benefits to provide healthcare benefits to individuals 65 and older as well as younger individuals with disabilities. Medicaid is a program that helps low-income individuals and is administered partially on a federal level and partially on a state level. For instance, there may be certain federal minimums that must be met, but then various states offer different levels of coverage or types of care above federal minimums. In some cases, elderly individuals that already qualify for Medicare may also qualify for Medicaid as well. 

Paid by State vs Paid by MACs

Medicaid services are paid for by the state, so state claim forms have to be filled out for covered services and procedures. Unfortunately, coverages and regulations vary from state to state so what is covered in one state is not always covered in another, or can be covered at a different level. Medicare, however, is a single-payer healthcare system that allows individuals to enroll with various insurance companies or Medicare Administrative Contractors (MAC). Reimbursement guidelines are set by the MAC.

Who Gets Paid When

In some cases, Medicare claims are paid directly to the provider and in other cases, they are paid to the patient. If the provider accepts assignment of the claim, then Medicare pays the provider 80% of the allowed amount and the other 20% has to be collected from the patient. If the provider does not accept assignment of the claim, then Medicare pays the patient the approved amount and they are responsible for paying the provider. Medicaid is always the payer of last resource, so any other benefits the patient has must be accessed first before Medicaid benefits kick in.