- Original Medicare is government-run coverage that uses private companies to perform billing and processing of claims and payments.
- Medicare uses private carriers to process requests for insurance coverage and review appeals.
- Medicare uses different carriers for each state or territory.
- Medicare Advantage, Medigap, and Part D offer health plans from private insurance providers.
- Original Medicare uses private carriers for durable equipment, claims, and business functions
Original Medicare operates as a fixed-fee-for-services organization. The Centers for Medicare and Medicaid contract with well-qualified doctors and hospitals that will accept Medicare terms and prices for patient services. Medicare uses carriers to process claims from members. Claims arise in many ways, but most are unpaid bills or charges paid by customers for which they seek reimbursement.
Comparison shopping is a great method for finding value in Medicare Advantage, Part D, and Medigap. These programs offer private plans with a variety of features, restrictions, and advantages.
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Fixed Fee-for-Services Organization
A fixed-fee-for-services organization is a type of managed care that provides freedom of choice for customers. The customers can use their choices of medical services instead of a directed path of treatment for everyone.
In this type of organization, customers can use any doctor or hospital that accepts Medicare. They are not required to consult with a primary care doctor or get referrals to specialists. If they use services outside of the network, then they must apply to a carrier for reimbursement or coverage.
History of Carriers
When enacted, The Centers for Medicare and Medicaid used contractors to handle certain Medicare claims and processing. They were called Part A Fiscal Intermediaries (or FI) and Part B carriers. The names changed with the passage of the Part D prescription drug amendments in 2003, and the CMS was directed to call these companies A/B Medicare Administrative Contractors (or MACs). Many people still refer to them as carriers.
Carriers are the Hub of Original Medicare
The Part B carriers process more than $300 billion in claims, bills, disputes, and appeals. They help educate providers and develop improvements for claims standards. The carrier’s responsibilities include the following tasks:
- Process claims for Original Medicare
- Make Medicare payments
- Account for Medicare payments
- Recruit and enroll Original Medicare service providers
- Review appeals and make reimbursements
- Review medical records as needed for claims
- Establish Local Converge Determinations to include ore procedures as medicinal applications grow
- Handle inquiries from service providers
The Importance of Local Coverage Determinations
Medicare A and B is a large medical care system serving a diverse population of millions of older Americans and disabled persons. With millions of determinations of coverage each year, it is important and difficult to maintain consistency from state to state and region to region.
Local coverage determinations help the system work consistently by providing peer guidance to the process of review and approval of billings and procedures. As one state advances a new direction in procedures, every other carrier gets the information and can apply it.
Carriers Process Claims by State or territory
Medicare publishes a list of carriers and the territories they serve. When a claim occurs, Medicare requests the member to send the claim to the carrier responsible for the area in which the claim occurred.
Filing a Claim with the Designated Carrier
Customers file claims or disputes with the carrier for the state or region where the costs occurred. The carrier may ask for more information to confirm the facts and may review medical records if needed to understand the situation.
The carriers routinely handle cases in which the provider bills the wrong party. For example, they may customer rather than Medicare, bill the wrong amount, or fail to bill Medicare at all.
MACs Service Customer and Providers
The MACs cover most of the processing that occurs in claims, disputes, and appeals. The learn and grow in knowledge and experience and help the system expand its ability to recognize situations and make decisions that carry out the intent of the laws and promote positive patient outcomes.
There are twelve (Part A/B) MACs covering the fifty states and territories; there are four MACs for durable equipment processing (called DME MACS). MACs work with the below-listed groups to make the claims and processing system work smoothly.
- Medicare Part A and B customers
- Medicare Part A and B medical service Providers
- Medicare Part A and B insurers
- Medicare Functional Contractors
Medicare: The Seniors’ Medical Services Program
Medicare is the national program for comprehensive hospital and medical insurance for older Americans. It has two basic types. First, it has the Original Medicare which consists of Medicare Part A and Medicare Part B.
Second, it offers private plans that provide coverage equal to Original Medicare called Medicare Advantage. The other parts of Medicare are the prescription drug coverage in Part D, and the gap insurance of Medicare Supplement.
- Part A is Hospital Insurance.
- Part B is Medical insurance. This part covers outpatient medical services and durable equipment.
- Part C is Medicare Advantage.
- Part D is the Prescription Drug benefit.
- Medicare Supplement
MACS work with DME and Functional Contractors
At the heart of the Original Medicare system, MACs work with Medicare, customers, and other private contractors. Medicare uses four MACs to process requests and payments for durable medical equipment. This is an important part of treatment and outpatient services.
MACs also work with functional contractors . These functional contractor companies provide specialized capabilities for Medicare. The functions include accounting, record keeping, call center operations, and program integrity.
Medicare Provides the Names of Carriers
Carriers serve an important function in the operation of Original Medicare. Medicare maintains a list of carriers and the areas that they serve. Customers must direct claims and questions to the carrier that serves the area where the claim occurred. Customers can call Medicare at 1-800-MEDICARE ( 800-433-4227).
Comparison shopping is important when selecting outside of the Original Medicare options. The private plans offered through Medicare include Medicare Advantage, Part D Prescription Drugs, and Medicare Supplement or Medigap insurance.
Weigh all the pros and cons of your greatest options with our free online Medicare comparison tool. Click here to get started!
