Billing in long term care means navigating two fundamentally different programs - often for the same patient. Medicare and Medicaid have different eligibility rules, covered services, payment models, and claim submission processes. This cheat sheet breaks down the key differences and shows you how to avoid the most expensive crossover billing mistakes.
Coverage Basics: Who Pays for What
Medicare covers skilled nursing care for up to 100 days after a qualifying hospital stay (3+ days). It pays for skilled nursing, PT, OT, SLP, and related services during this period.
Medicaid covers custodial (non-skilled) long term care for individuals who meet financial eligibility requirements. In most states, Medicaid is the primary payer for residents who have exhausted Medicare benefits or don't qualify.
Dual-Eligible Patients: The Crossover Challenge
Patients eligible for both Medicare and Medicaid (dual-eligibles) create the most complex billing scenarios. Medicare is always the primary payer. After Medicare processes the claim, the remaining balance crosses over to Medicaid.
Common mistake: Billing Medicaid before Medicare has processed the claim, or failing to bill the crossover at all. Both result in lost revenue.
PDPM vs State Medicaid Rate Structures
Medicare pays SNFs under PDPM - a case-mix adjusted per diem model. Medicaid payment varies by state: some use case-mix systems, others use flat per diems, and some use managed care capitation.
Your billing system must handle both payment models simultaneously and track which rate structure applies to each patient on each day of their stay.
The Medicare-to-Medicaid Transition
When a patient transitions from Medicare-covered skilled care to Medicaid-covered custodial care, the billing model changes completely. Missing this transition - or billing the wrong payer after it occurs - creates denials and compliance risk.
Fix: Automate transition date tracking and trigger a billing review when Medicare benefits are exhausted.
Common Crossover Billing Mistakes
1. Not submitting the Medicare claim first for dual-eligibles. 2. Failing to bill the Medicaid crossover after Medicare adjudicates. 3. Using the wrong Medicaid rate after Medicare exhaustion. 4. Not updating the payer sequence when eligibility changes. 5. Missing the Medicaid timely filing deadline after waiting for Medicare processing.
Each of these mistakes costs facilities real dollars - often across dozens of patients simultaneously.
How Pono Helps
Pono's crossover claim handling automatically sequences Medicare and Medicaid billing, tracks transition dates, and ensures no crossover claim falls through the cracks.
Want us to audit your crossover claim process for missed revenue?
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