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Just as individuals seek physical therapy for a variety of conditions, they arrive with different types of health insurance. Each payer, from government plans to commercial entities, has its own billing requirements. Navigating these rules can be difficult for health care providers under any circumstances. This column will focus specifically on the case of "dual eligible" beneficiaries—people who qualify for health care coverage under both Medicare and Medicaid. As a physical therapist, you need to be able to identify this population and know how to troubleshoot billing issues.

The Rules

Dual-eligible beneficiaries receive health coverage from both Medicare and their state Medicaid program. Typically, an individual qualifies for Medicare coverage because of his or her age (generally 65 or older) or specific disability. That same person may qualify for additional benefits under Medi-caid if his or her income falls below a certain threshold or if the beneficiary has exceptionally high medical bills. Under dual-eligible scenarios, Medicare covers acute care services, such as short-term hospital stays. Medicaid pays for the Medicare premium, cost sharing, and long-term care services.

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  1. "Qualified Medicare Beneficiary Indicator in the Medicare Fee-for-Service Claims Processing System." Medicare Learning Network, Centers for Medicare and Medicaid Services. http:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9911.pdf. Accessed November 27, 2017.
  2. "Bad Debt." Noridian Healthcare Solutions. https://med.noridianmedicare.com/web/jea/audit-reimbursement/audit/bad-debt. Accessed November 27, 2017.

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