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