What Is a Medicare Contractor and How Do They Help with Appeals?
Medicare relies on private contractors to support Original Medicare (Part A and Part B) administrative duties, such as claims processing and appeals. Both Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) are involved in the appeal process.
These contractors have been part of a large-scale effort to reduce Medicare overhead costs and shorten claims processing time. Medicare contractors work under the oversight of the Centers for Medicare and Medicaid (CMS), the federal body that manages the Medicare program. Each MAC is responsible for processing Medicare Part A and Part B claims in one specific geographic region.
If you decide to appeal a coverage or payment decision, MACs are involved in the first stage of this process, known as redetermination. To find the MAC for your state, see the Contractor Directory on CMS.gov. You can also refer to your Medicare Summary Notice (sent to you every three months for contact information.
If your appeal is denied, you can request the next level of appeal, called a reconsideration. This is when the QIC gets involved. The QIC, an independent contractor not involved in the first-level (redetermination) decision, reviews your appeal and typically sends you a Medicare Reconsideration Notice about two months after receiving your appeal request. The redetermination notice includes the QIC's contact information. For detailed instructions about filing Medicare appeals, see Medicare.gov .
What Medicare contractors do
Medicare administrative contractors have many responsibilities, such as:
- Beneficiary payments
- Medicare provider payments
- Supplier payments
- Home health and hospice claims
- Durable medical equipment (DME), orthotics, and prosthetics claims
- Customer service for beneficiary and provider inquiries
- Collecting overpayments or underpayments
- Investigating potential Medicare fraud
- Provider enrollment and training
MACs fall into two different types. Medicare Part A and Part B claims, as well as home health and hospice claims, are handled by A/B MACs. Durable medical equipment (DME), orthotics, and prosthetics claims are processed by DME MACs.
On the Medicare provider side, MACs work closely with hospitals and doctors to ensure that Medicare coverage and payment requirements are met.
Medicare contractor competitive bidding process
All Medicare administrative contracts must be opened up to a competitive bidding process no less than once every five years. A contract for a single jurisdiction can be worth hundreds of millions of dollars. CMS is required to select Medicare contractors based on both price and performance evaluations. Any contract renewal must demonstrate that the Medicare contractor exceeded performance requirements.
Under the MMA, all Medicare contractors must have a compliance program in place to monitor its conduct and ensure that it follows the requirements of the Medicare program. Medicare contractors must also submit to periodic audits and quality assurance reviews.
Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by private companies approved by Medicare and provide Medicare Part A and Part B coverage. Medicare prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. A Medicare Supplement plan is a health insurance plan provided by a private company that fills in the "gaps" in original Medicare coverage.
Medicare has neither reviewed nor endorsed this information.Source: www.planprescriber.com