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Most people think Medicare is a government program. That’s only partly true. While Congress created Medicare, and continues to develop Medicare coverage and appeal rules, decisions to pay claims are actually made by private companies. The government does not make those decisions. This was one of the compromises made in order to pass Medicare in 1965 – and the public-private partnership continues to date.

Indeed, the entities granting or denying coverage, and those deciding whether or not to pay claims, are mostly private insurance companies. For example, Anthem is the parent company of “National Government Services,” one of the major Medicare claims administrators. Another Medicare administrative contractor, “MAXIMUS,” is a for-profit company that helps state, federal and foreign governments administer programs.

In addition, about 30% of Medicare beneficiaries are enrolled in private “Medicare Advantage” plans. These plans are also run by private companies, mostly within the insurance industry, and they make Medicare initial coverage decisions for their enrollees.

We know that when Medicare is working right and covering necessary care, everyone is content.  But, if coverage is denied unfairly… don’t blame the government. It’s probably not “Medicare” that made the decision; it’s most likely a private insurance company that’s paid by Medicare to make coverage decisions.

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