Medicare-Medicaid Audit World
There has been much discussion about post payment reviews conducted by CMS’ Recovery Audit Contractors (RACs). The discussions center on the burdens imposed on providers by the RAC’s demand for documents and the appeals necessary to fight unwarranted payment demands. Prepayment reviews conducted by the CMS Medicare Administrative Contractors (MACs) may turn out to be much worse!
What are MACS?
An A/B MAC is an entity tasked with processing payments submitted by Part A and Part B providers in the traditional fee-for-service Medicare program. MACs were authorized by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 and have now replaced the former fiscal intermediaries and carriers. CMS began awarding A/B MAC contracts in 2006 based upon its division of the United States into 15 jurisdictions. By 2010, CMS decided that the program would be more efficient if there were only 10 A/B MACs and so is in the process of merging 5 of the jurisdictions with other existing jurisdictions. While the original jurisdictions were identified by number, the new jurisdictions are identified by letter. A history of CMS’ award of A/B MAC contracts is found here and a table listing the current MACs by state (including website) and the state’s original and consolidated jurisdiction is found here.
What are the MACs doing?
According to Chapter 3 of the Medicare Program Integrity Manual (PIM), “[T}he MACs have the authority to review any claim at any time… The MACs have the discretion to select target areas because of:
- High volume of services;
- High cost;
- Dramatic change in frequency of use and/or
- High risk problem-prone areas
What this means is that a MAC, unlike a RAC, does not have to obtain CMS’ approval of what procedures it will subject to prepayment review. Also, there is currently no limitation, other than the MACs discretion, as to how many Additional Document Requests (ADR) a MAC may make. As the PIM makes clear, when documents are requested:
[t]he requested documentation is to be submitted within 30 calendar days of the request. The reviewer has the discretion to grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 45.
Once the MAC has all the records it requested, it has 60 days to make a decision.
And this is not the worst part…
The worst part of this process is that it is ongoing. If the MAC feels that a certain procedure is being miscoded or that there is no medical necessity for a procedure, it will conduct a prepayment review of each claim submitted for extended periods of time. This means the provider will be subject to ongoing requests for records and suffer a substantial negative impact to its current cash flow.
What should you do if are notified of a prepayment review?
Make sure you provide the requested records in a timely fashion. Inaction will prove very expensive.
Promptly contact the MAC to determine what the MAC believes to be the problem with your billing and how it believes the problem should be corrected. If you agree with the MAC, immediately correct the problem and demonstrate to the MAC through revised future billings that the problem has been resolved. Once a number of correct bills have been submitted, discuss with the MAC an end date for the prepayment review.
If you disagree with the MAC, respond to its record requests and if payment is denied, appeal. If you appeal, you should give serious thought to hiring counsel. In my experience, a knowledgeable attorney is able to present your position in a more persuasive manner than a layperson. In addition to increasing your chances of being successful, continuing attorney involvement and cogent presentations may make the MAC more cautious before deciding whether it wants to conduct other prepayment reviews of your billings.
The best solution, however, is to make your billing invisible to the MACs by constantly auditing your processes and procedures to ensure that your Medicare billing is appropriate and accurate.
Please contact us if we can be of any assistance in explaining the workings of the Medicare-Medicaid Audit World or in helping to resolve an issue with any of CMS’ legion of auditors.