Medicare administrative contractors process claims for health care services rendered by a provider. Contractors serve as the primary contact between Medicare's fee-for-service program and enrolled health care providers.
On the provider side, Medicare administrative contractors enroll physicians, nurse practitioners, physician assistants and other specialty health care providers in the Medicare program. Contractors assist providers in answering questions regarding the program and educating providers on Medicare coding and billing requirements. They are responsible for then processing the claim into a payment for the provider and ensuring compliance with billing regulations. Contractors also assist Medicare beneficiaries with plan inquiries, enrolled benefits and online resources.
According to the Centers for Medicare and Medicaid Services, Medicare administrative contractors process nearly 5 million claims per day and disburse more than $365 billion each year in payments to health care providers. The 2003 Medicare Prescription Drug, Improvement and Modernization Act mandates Medicare contractor reform to improve the competency and quality of Medicare administrative contractors. Applicants must adhere to specified performance-based evaluation criteria in order to qualify for a position as a Medicare administrative contractor. The Centers for Medicare and Medicaid Services significantly decreased operational costs by implementing these criteria and by hiring competent, innovative Medicare administrative contractors.