1. Medicare Overview
✔ Federal program for patients aged 65+ or with disabilities
✔ Covers Part A (hospital), Part B (outpatient), Part C (advantage), Part D (drugs)
✔ Follows national billing rules set by CMS
2. Medicaid Overview
✔ Joint federal-state program for low-income individuals
✔ Benefits and billing rules vary by state
✔ Requires pre-authorization for many services
3. Commercial Payers
✔ Private insurance companies like Aetna, Cigna, UHC
✔ Coverage varies by employer and plan type
✔ Negotiated fee schedules and payer-specific billing policies
4. Key Differences
✔ Medicare uses fixed rates; commercial plans negotiate rates
✔ Medicaid often pays less and requires more documentation
✔ Commercial insurers have varied timelines and rules
5. Common Challenges & Fixes
| Challenge | Fix |
| Confusing payer rules | Maintain a quick-reference guide for each payer |
| Denied services across payers | Review authorization requirements before scheduling |
| Delayed payments from Medicaid | Submit claims electronically and follow state timelines |
| Multiple plans for one patient | Confirm coordination of benefits before billing |
