Difference between Medicare and Medicaid Credentialing

Besides dealing with medical cases, the healthcare practitioner has to deal with a lot of paperwork to fulfill the credentialing requirements. The government in the United States started two funded initiatives naming Medicaid and Medicare programs.  

The purpose of these programs was to provide easily accessible healthcare services to every individual specially seniors and disabled individuals.  

The basic difference between these standards is that they serve different groups under different protocols. For getting the better understanding of Insurance credentialing differences, it is necessary to differentiate the two.  

One has the criteria of a specific age group to become eligible. The other deals with people who have limited financial resources. The difference between costs also set them apart from one another.  

Don’t know the difference between the two? You are at the right place. Here is the complete information you need to know about the Medicare and Medicaid programs. Let’s dive into the details of both.   

Overview of Medicare Credentialing 

Medicare is the health insurance of US. The people 65 years of age or older, as well as those under 65 years with certain disabilities are covered by Medicare.  
Before moving to the Medicare credentialing, let’s have a quick review of what Medicare covers.  

It generally covers four parts. Part A deals with hospital insurance like Inpatient hospital care, nursing care, and some home health services. Part B is Medical Insurance covering outpatient care and prevention services. Medicare advantages are in part C. Part D encompasses drug prescriptions.  

Medicare credentialing is the process of verifying the qualification of healthcare providers to ensure that they meet the standards required for availing the services of Medicare beneficiaries. This enables them to bill Medicare for their services.  

Benefits of Medicare Credentialing:  

• Almost 66 million Medicare beneficiaries are easily accessible to healthcare providers through credentialing. This increases the patient ratio and more chances to improve patient practice.  

• No risks of denials and legal penalties with Medicare credentialing. You can easily apply or claim Medicare services without worrying about legal action.  

Main Steps in Medical Credentialing:  

• For the preparatory process, you can have a look at CMS official Medicare enrollment resources.  

• You should have an NPI (National Provider Identifier) before putting in an application for Medicare credentialing.  

• Next step is enrolling in Medicare through PECOS (Provider Enrollment, Chain and Ownership system) using the required documentations and professional information. Medicare Administrative Contractor (MAC) reviews your application.  

• Once you have enrolled, you have to follow the specific credentialing guidelines and discipline to maintain your eligibility status.  

• Processing time is approximately 60-90 days.  

• Revalidation time is 5 years. Keep track of that. Missing the track of time means a problem in claiming your eligibility.  

Overview of Medicaid Credentialing 

Medicaid is the state program that deals with people who have limited financial resources. It also covers children, disabled individuals, and pregnant women. Almost 90% Americans get coverage from Medicaid.  

However, the benefits Medicaid offers, and its eligibility criteria vary depending on state. Modified Adjusted Gross Income (MAGI) also affects the eligibility of Medicaid.  

The specification of federal law makes a person eligible for Medicaid if the household income is below 133% of the federal poverty level.  

 Let’s have a look at the Medicaid plans. Although services vary depending on the state, the common ones are Inpatient and outpatient department services, clinic visits, laboratory and diagnostic tests, and some of the home health plans.   

The process of confirming that healthcare professionals are qualified enough to meet the requirements for Medicaid services is Medicaid credentialing.  

Benefits of Medicaid Credentialing: 

• Increased patient exposure and database.  

• More trust among the patients because of compliance with the legal policies.  

• Access to Medicaid billing can enhance revenue for services reimbursements. 

• Medicaid approved fee schedules make adherence to compensations easier.   

Main Steps in Medicaid Credentialing: 

• There is a difference in Medicare vs. Medicaid provider enrollment documentations. It is necessary that you study the enrollment processes of your state before applying.  

• For Medicaid credentialing, the first step is to collect the necessary documentation considering your state requirements. These commonly include certificates and licenses, TINS, and provider agreements.  

• Complete the government payer enrollment process by submitting the enrollment application on the Medicaid website of your state.  

• After reviewing, validation of eligibility of healthcare provider for legalities is the next step. 

• You will get an official Medicaid provider number. Maintain compliance with the credentialing standards.  

Key Differences in Requirements & Process 

	Medicare Credentialing	Medicaid Credentialing
Age Group	Covers the 65 years or older individuals Individuals younger than 65 with any disease or illness.	Covers families and persons with low socioeconomic status.  Children and pregnant women are also among beneficiaries.
State Dependency	Do not have much state dependent demands.	State affects the requirements and services.
Cost	Pay some expenses in the form of premiums and deductibles.	Do not pay for services.
Enrollment	Require PECOS enrollment	Need to follow state Medicaid enrollment process.

Challenges with Each Type 

To enjoy the benefits of Medicaid and Medicare credentialing programs, you must know that it is not as easy as it seems. Certain insurance credentialing differences and denials can come in your way.   

The possible challenges that you can encounter during the credentialing process are discussed next.  

Your test starts at the first step. Beginning with the completion of extensive documentation for the enrollment purpose is quite tiresome. You have to be extra careful in this area as missing or outdated documents can increase the chances of rejection.  

No matter whether you are going with Medicare or Medicaid credentialing, both processes require an ample amount of time for processing. This can cause delays in dealing with the patients.  

Keeping an eye on the renewal process is demanding. You have to pay extra attention to keep your data updated and renewed to enjoy privileges.  

When conducting credentialing of healthcare professionals. Strict compliance among the state, federal, and payer standards is essential for streamline process.  

Failure to talk back to Medicare or Medicaid when they reach you out for additional documents can put down your application.  

The new updates and policies related to credentialing need specific attention. Missing out an update can harm you in future. The best way to keep yourself updated is joining credentialing forums, subscribing to Medicare and Medicaid newsletters and attending compliance workshops.  

Which Credentialing is Right for Your Practice? 

Stuck between Medicaid and Medicare credentialing? Let us make it easy for you. There are certain factors that help in making the decision easier. First, practicing state had a great impact on Medicaid services. Decide smartly where to pursue your practice.  

There is another scenario that may help you out. Look if you are eligible for both the Medicaid and Medicare credentialing. In that case there is a Dual Eligible Special Need Plan. The best part is you can avail yourself of the benefits of both Medicare and Medicaid programs in one plan.  

Tips for Success in Medicare & Medicaid Enrollment 

Is it your first time getting enrolled in Medicaid and Medicare? No worries. We’ve got you covered. The following tips will help in getting the enrollment done with any hindrance.  

Medicare Enrollment: 

•  For the first time signing up for Medicare enrollment, it is crucial to keep track of Initial enrollment period dates. IEP includes a 7-month period; 3 months before 65^th birthday, the birthday month and 3 months after the 65^th birthday.   

• Keep track of all the essential documents and certificates required during the enrollment application.  

• Decide whether you want to enjoy the benefit directly via Original Medicare or want to opt for a Medicare advantage plan. The Federal government administers the original Medicare (part A and B). On the other hand, private insurance companies offer Medicare advantage plans (part C).  

• Choose the plan wisely considering the health care services you must use during the year. Explore different Medicare plans and make an estimate for what you must pay and what you will get. 

Medicaid Enrollment:   

• Figure out the eligibility criteria. Medicaid is focused on providing healthcare services to a specific income class. Go through the income and asset requirement criteria set by the Medicaid Program.  

• Gather all the necessary personal information, financial documentation and residency proof. Try to fill in the application form without any error. Attach the supporting documents.  

• Proofread the Medicaid information to avoid any resulting queries.  

• Ensure timely response to updates or notifications during the appealing process. 

• Once your application is approved, maintaining compliance with the Medicaid eligibility is crucial. to Try to report the changes or updates regarding any documentation for preserving the eligibility status.   

Conclusion

Following Medicare and Medicaid credentialing is more than just reading the articles. Adopting an organized and practical approach, following compliance standards can help to get it done in time. Treat your patients without any hassle.  

Hope this article has helped in understanding the difference between credentialing, enrollment, and privileging. If there is still any confusion, take help from us regarding the Medicaid and Medicare credentialing support services.  

Get ready for a fast credentialing with the smooth services of CREDEX Healthcare. Contact us today! You put your complete focus on patient care while we focus on streamlining your credentialing process.  

Frequently Asked Questions:  

1. Is Medicare credentialing harder than Medicaid? 

There is no specificity stating that one is harder than the other. Both of these have their own challenges.  

Here we are summing up the basic challenges that can help you decide which is harder. Medicare credentialing is a federal program which allows the use of standardized requirements.  

Medicaid is a state-dependent process that does not follow any standard protocol, having diverse screening procedures and timelines.  

2. Can I be credentialed with both? 

Usually, one credentialing application is enough. But if you want, check if you fulfill the eligibility criteria of both the programs. However, two different practicing locations and billing using two tax IDs will be done.  

3. How long does Medicare credentialing take? 
   Medicare provider enrollment application almost takes 40 days. Moreover, other factors like how compact the application was and whether there was any error in the application, also affect the timeline.  

On the whole, Medicare credentialing can take from 90 to 120 days. Again, other factors like state reviewing or missing documentation can affect the timings of procedure. 

4. What is Dual Eligible Special Needs Plan (D-SNP)?  

The people that are eligible for Medicaid and Medicare program are dual eligible. For such people, there is a single plan that serves the perks of both programs.  

It helps to provide managed care to the individuals that hold dual eligibility.  

5. How do I check my Medicare Provider enrollment status?  

For checking your enrollment status, you should know about the MAC (Medicare Administrative Contractor) of your area.  

Locate the “Provider enrollment” status on the MAC and enter your Application Tracking number and other required details on the tab. You will get the enrollment status within seconds.