Medicare carriers are contracted by the government to oversee the administration and processing of Medicare policies. They handle claims appeals, identify billing errors, and respond to beneficiary inquiries. Medicare providers must meet enrollment requirements and agree to reimbursement terms. Carriers review claims and establish payment policies. Providers receive payment through prospective payments or relative values. Carriers are reviewed annually and must stay current on policy changes to be eligible for renewal.
A Medicare carrier, or Medicare Administrative Contractor (MAC), serves as the primary point of contact for Medicare providers. Contracted by the government, a Medicare carrier is typically a regional company that oversees the administration and processing of Medicare Part A and Part B policies. The operator is also the provider’s primary source for coverage, billing, and enrollment questions . In addition, Medicare carriers also handle claims appeals, identify billing errors, and respond to any beneficiary inquiries.
Medicare carriers vary by state and work with assigned providers in their area to ensure they meet enrollment requirements. To become a Medicare provider, applicants must apply, have a valid medical license in their state, and meet U.S. government-specified non-discrimination standards. In addition, the provider must agree to the Medicare reimbursement terms. It is the Medicare carrier’s responsibility to ensure that the provider understands these terms.
While carriers are required to process claims under government regulations, as regional companies, they have the authority to set local policies. A Medicare carrier, therefore, must review all Medicare claims and determine whether or not the claim qualifies for Medicare reimbursement. The carrier is then responsible for developing payment policies for the states in its area. Once these local medical review policies, also known as local coverage determinations, have been established, the Medicare carrier evaluates each Medicare claim to ensure that the services provided are reasonable and necessary.
Typically, Medicare providers receive payment in one of two ways, through prospective payments or relative values. Used for Medicare Part A, a contingent payment is a fixed amount of money awarded for the type of care provided. Providers receive this standard rate for their services, regardless of their actual rates for any procedures or services. Relative value fees, on the other hand, are used for Medicare Part B policies and, similar to private insurance reimbursements, assign a standard value for each service. The doctor is then reimbursed according to the fee plan outlined.
Initially contracted on an annual basis, Medicare carriers are reviewed annually to ensure they meet guidelines set by the Center for Medicare and Medicaid Services (CMS). If deemed suitable, the carrier can then renew the contract for up to four additional years. To be eligible for renewal, a carrier must stay current on policy changes through regular and ongoing training and development.
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