Medicare and Medicaid dual eligibility situations can be tricky. Especially when it comes to claim crossovers. If you're not accustomed to dealing with these, the process might feel like trying to solve a complex puzzle — without all the pieces. Let’s break it down to make sense of what happens when patients hold both Medicare and Medicaid coverage.
Understanding Dual Coverage
Individuals who qualify for both Medicare and Medicaid are known as "dual eligibles." Medicare typically serves as the primary payer, while Medicaid acts as the secondary. This generally means that Medicare pays first for any covered services, and Medicaid may cover some part of the remaining balance.
But how do claims actually get from Medicare to Medicaid? That’s where the concept of a "claim crossover" comes into play.
What Is a Claim Crossover?
A claim crossover is the process through which Medicare automatically forwards (or "crosses over") a claim to Medicaid after processing it. This eliminates the need to submit two separate claims for the same service — at least in theory. However, the process isn’t always straightforward.
For this to work smoothly, the state Medicaid program must have a working agreement with Medicare — known as a Coordination of Benefits Agreement (COBA). Each state’s Medicaid program has its own nuances, which can complicate matters.
Common Billing Issues with Crossover Claims
Timing and Delays
It’s not uncommon for crossover claims to experience delays. After Medicare processes a claim, it doesn’t beam instantly over to Medicaid. There can be a significant lag — sometimes as long as several weeks. This can mess with cash flow and create reconciliation headaches.
Missing Crossovers
In some cases, claims never make it to Medicaid. Why? Incorrect patient information, outdated eligibility details, or even systemic glitches can cause crossovers to fail. When this happens, billers must manually intervene, often requiring resubmission of claims to Medicaid.
Medicaid Denials
Even when a claim successfully crosses over, Medicaid may still deny it. Reason codes like 22 (Medicaid cannot pay this claim until Medicare has paid) might appear, often signaling that additional information or corrections are needed. Sometimes, the denial is due to Medicare’s payment meeting or exceeding Medicaid’s allowable rate — essentially leaving nothing left for Medicaid to cover.
Navigating Crossover Claims
Ensuring Correct Patient Information
First things first — correct patient information is non-negotiable. Any discrepancies in demographics or insurance data between systems can lead to claim rejections. Double-check and ensure the patient’s Medicare and Medicaid details match exactly.
Monitor and Follow Up
Don’t just submit and forget. Track your crossover claims regularly. Use payer portals (if you have the patience for the hold times and cumbersome navigation) to verify claim status and address any issues promptly.
Leverage Technology Wisely
Some practices use clearinghouses or practice management systems that can automatically alert them to crossover claim statuses. This can save time and reduce manual tracking. However, be cautious — these systems aren’t foolproof and still require occasional manual oversight.
Responding to Denials
When faced with a denial, act quickly. Analyze the denial code and determine the necessary steps for resubmission. Sometimes, simply including an EOB from Medicare can clear things up. Other times, a detailed call to Medicaid may be necessary to solve the issue.
Working Smarter, Not Harder
Handling dual eligibility claims can be labor-intensive, but understanding the mechanics behind crossovers can help. With dual coverage, both Medicare and Medicaid have a role in ensuring patients get the care they need without providers facing undue financial strain. It requires diligence and persistence.
In the end, the goal is to minimize the manual effort required to get claims paid. Understanding the quirks of crossover claims allows billing teams to anticipate common problems and address them proactively. Stay informed, stay diligent, and the process becomes less of a guessing game.
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