Credentialing With Medicare and Medicaid: Essential Tips to Know
Credentialing with Medicare and Medicaid can feel like a maze, especially when serving patients across state lines. It’s a necessary but often confusing process to ensure you get paid for your services. Whether you’re new to credentialing or just trying to understand why it’s so complicated, I’ve got you covered. Let’s dive into how to navigate the process step by step.
Key Takeaways:
- Credentialing with Medicare and Medicaid must be done separately for each state.
- Medicare is administered through MACs, requiring applications in each state where you serve patients.
- Medicaid requires state-specific credentialing, even for Managed Care Organizations.
- Out-of-state billing can be tricky—consider credentialing in neighboring states if serving cross-border patients.
- Educating your staff on proper credentialing processes is key to avoiding billing issues.
Medicare and Medicaid: What’s the Deal?
Before we discuss the specifics of credentialing for Medicare and Medicaid, let’s define these programs.
Medicare and Medicaid are federally funded programs, but they work differently. While the federal government entirely funds Medicare, Medicaid funds it from federal and state governments. Each state runs its own Medicaid program, which means credentialing with Medicaid is done state-by-state.
Now here’s where things get tricky—Medicare is also administered by different contractors in each state. These contractors are called Medicare Administrative Contractors (MACs). So, even though Medicare is a federal program, you still need to apply separately to the MAC in each state where you want to serve patients.
Credentialing in Multiple States: A Bit of a Hassle, But Necessary
Here’s the big thing about credentialing for Medicare and Medicaid—you can’t just fill out one application and call it a day. If you’re serving patients across state lines, you must provide credentials separately for each state. For example, if you’re based in Portland, Oregon, but you’re also seeing patients in Vancouver, Washington, you’ll need to complete four different applications:
- Medicare in Oregon
- Medicare in Washington
- Medicaid in Oregon
- Medicaid in Washington
You can’t use the same application for multiple states, even though it’s technically the same program. Yes, it’s a hassle, but it’s an absolute must if you want to get paid for serving patients in different states.
Applying for Medicare: Picos to the Rescue
If you’ve ever tried to navigate the Picos system for Medicare credentialing, you know it can be overwhelming. But don’t worry—Picos is where you must submit your applications for each state’s Medicare program. And yes, if you’re credentialing for multiple states, you must submit separate applications for each one. Unfortunately, it’s not one of those “one and done” situations.
Medicare may be federally funded, but as mentioned earlier, it’s administered by MACs in different regions. So, if you’re serving patients across state lines, you’ll need to get credentialed with the MAC that handles Medicare for each specific state. And if you’re not credentialed in that state, you can’t bill for services provided to patients with out-of-state Medicare plans. Period.
Medicaid: A Whole New Level of Complexity
Now, let’s talk about Medicaid credentialing. Since individual states run Medicaid, it probably makes sense that you’d need to credential with each state’s Medicaid program separately. No surprises here, right? However, it gets complicated when dealing with Medicaid Managed Care Organizations (MCOs).
Some commercial insurance providers offer Medicaid MCO plans. But, even if you’re credentialed with that commercial insurer, if you’re not credentialed with the state’s Medicaid program, you still can’t bill for services provided to that patient.
For instance, if you’re credentialed with Blue Cross Blue Shield in Oregon but not with Washington’s Medicaid program, you can’t bill for a patient’s Medicaid MCO plan—even if Blue Cross Blue Shield covers them in their home state. Wild, right?
| Scenario | Can You Bill? |
|---|---|
| Credentialed with Oregon Medicare | Can bill Oregon Medicare patients, but not Washington Medicare patients |
| Credentialed with Oregon Medicaid | Can bill Oregon Medicaid patients, but not Washington Medicaid patients |
| Credentialed with Blue Cross Oregon (MCO) | Can bill Oregon MCO patients, but not Washington MCO patients (if not credentialed with Washington Medicaid) |
The Out-of-State Billing Dilemma
One of the biggest issues people face when credentialing for Medicare and Medicaid is the out-of-state billing dilemma. Let’s say you’re based in Idaho, but it’s more convenient for your patients to go to a clinic in Oregon. If you’re only credentialed with Idaho’s Medicaid or Medicare, you won’t be able to bill for services provided to those patients in Oregon. It’s not just about where your practice is—it’s about where the patient’s insurance is based.
If you see many patients from a neighboring state, going through the extra steps to be credentialed with that state’s Medicare and Medicaid programs might be worthwhile. Otherwise, you’ll need to talk awkwardly about paying out of pocket with your patients.
Educating Your Staff Is Key
One of the most overlooked aspects of Medicare and Medicaid credentialing is ensuring your staff is up to speed. If you’re credentialed in multiple states, your staff needs to know which patients you can bill for—and which ones will have to pay out of pocket.
For example, if you’re credentialed with Medicare in Oregon and Washington and a patient from Washington walks in, your staff needs to know how to register them under Washington Medicare. If they accidentally register the patient under Oregon Medicare, you could have a billing nightmare. The last thing you want to do is explain to a patient why their claim was denied because of a simple oversight.
What is the difference between Medicare and Medicaid?
Medicare is a federally funded program primarily for individuals 65 or older, while Medicaid is a joint federal and state program for low-income individuals. Each state runs its own Medicaid program, meaning credentialing with Medicaid must be done separately in each state.
Do I need to have separate Medicare credentials in each state?
Yes. Medicare is administered by different Medicare Administrative Contractors (MACs) in each state, requiring separate applications for each state where you want to serve patients. Even though Medicare is a federal program, you must apply in each state.
How does Medicaid credentialing work across states?
Medicaid requires state-specific credentialing, even for Managed Care Organizations (MCOs). If serving patients across state lines, you must be credentialed with each state’s Medicaid program to bill for services provided to out-of-state patients.
Can I use the same application for multiple states?
No, you cannot use the same application for multiple states. Each state requires a separate credentialing application, whether for Medicare or Medicaid, making it essential to submit credentials for each state you plan to serve patients in.
What happens if I’m not credentialed in a neighboring state?
If you’re not credentialed in a neighboring state, you cannot bill for services provided to patients with Medicare or Medicaid from that state. Credentialing in neighboring states can help avoid billing issues when serving cross-border patients.
How can staff training prevent billing errors?
Based on your credentials, staff training ensures your team understands which patients are covered. If your staff accidentally registers an out-of-state patient under the wrong state’s Medicare or Medicaid, it could result in billing issues and claim denials.
Why should I consider credentialing in neighboring states?
If you serve many patients from a neighboring state, credentialing in that state can simplify the billing process and ensure you can bill for their Medicare or Medicaid plans. This prevents awkward conversations about out-of-pocket payments due to lack of coverage.
Wrapping Up the Confusion: Stay Credentialed, Stay In-Network
Credentialing for Medicare and Medicaid might be a pain, but it’s necessary if you want to provide services to patients across state lines and get paid for them. Make sure you submit separate applications for each state and educate your staff on handling patients with out-of-state plans. And, if you’re seeing enough out-of-state patients, getting credentialed in neighboring states might be worth your while to make the billing process smoother.
Got any questions about Medicare and Medicaid credentialing? Leave them in the comments!