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Medicare Billing Vs. Medicaid Billing: What’s Different About Them?

Medicare Billing Vs. Medicaid Billing: What's Different About Them?
Here is what’s different about Medicare billing and Medicaid billing.

Many people might think that Medicare and Medicaid are practically twins. Both of them are healthcare programs that are provided by the government, and it was even at the exact same time when they were both made. On top of that, they have similar-sounding names. This can make it feel like Medicaid and Medicare billing are pretty much the same thing.

This is far from true, however. Each of these programs differs vastly, and we want to take the time to identify those differences for you. Here is what’s different about Medicare billing and Medicaid billing.

Medicare Billing

Medicare was meant to help the elderly pay for their outpatient and inpatient bills. The program assists those who are at least age 65, those with permanent disabilities, and those who have either amyotrophic lateral sclerosis, also known as ALS, or end-stage renal disease (ESRD). 

Medicare is divided into four kinds of coverage plans, which are labeled as parts A through D. We’ll describe each of these different coverage plans:

  • Part A:  covers some hospice and health for home care, as well as inpatient care that is provided either in skilled nursing facilities or hospitals.
  • Part B: covers costs from services such as outpatient physical therapy services and physician services.
  • Part C: provided to patients by private organizations that teamed up with Medicare.
  • Part D: covers prescription drug plans offered by private organizations

As for the billing policies, there are a few main ones we would like to cover. They are among the most commonly discussed rules. These are some of the billing policies that medicare billing must follow:

  • Requirements for POC recertification and progress notes.
  • Must abide by the 8-minute rule, which determines the number of units that a provider is allowed to bill for any one service.
  • Supervision requirements
  • Must follow the guidelines that are made by the ABN (Advance Beneficiary Notices of Noncoverage.)

With regards to completing claim forms and getting them submitted, Part A needs UB-04 forms, while Part B will use CMS-1500 forms. As for part C billing forms, it will depend on the state in which you live and your specific payer.


Unlike Medicare, which is meant to help the elderly population, Medicaid is meant to assist those who are impoverished. While the qualifications are slightly different with each state, you often qualify if you are making between 100% and 200% under the or federal poverty level (FPL), while also being pregnant, a caregiver, elder, child, or have a disability.

These are among the more general guidelines for Medicaid billing:

  • Overpayments must be returned inside of 60 days.
  • Guarantee that all medical records are signed, accurate, dated, and capable of being read.
  • Only covered services are billed
  • Make sure that beneficiaries are able to apply for furnished services.

Something to note is that both the state and federal governments are involved with Medicaid, so if national and state guidelines conflict with each other, you have to follow whichever rules are stricter.

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This entry was posted on Thursday, September 16th, 2021 at 3:46 pm. Both comments and pings are currently closed.