Medicare MAC Audits & Appeals

Healthcare Professional Looking at Medical Records.

Strong Federal Oversight on Medicare Claims Means Your Healthcare Practice Needs to Keep in Compliance. Our Healthcare Audit Attorneys Will Help You Do That.

The MAC (Medicare Administrative Contractor) is the Medicare contractor responsible for processing and paying Medicare claims for a certain geographic region. They are responsible for identifying and correcting Medicare overpayments and underpayments. In addition, the MAC is responsible for processing Medicare provider appeals.

One tool the MAC uses to target improper claims is prepayment edits. There are two types of prepayment edits: NCCI Edits (National Correct Coding Initiative) and MUE Edits (Medical Unlikely Edits). These are automated edits based on methodology developed using CPT coding guidelines and input from the AMA and other medical providers across the country. Medical providers may see these edits on their Medicare explanation of benefits.

NCCI & MUE Edits

The NCCI Edits are intended to promote correct coding methods and to control improper payments. Just because a claim hits an edit does not mean the claim is not payable. If the services were appropriate based on the specific circumstances and an appropriate modifier was used when the claim was billed, the claim can be eligible for payment. The provider’s medical record must contain information that supports the need for the service and the use of the modifier.

The MUE Edits attempt to reduce inappropriate payments by setting the “maximum units of service that a provider would report, under most circumstances, for a single beneficiary on a single date of service.” Because these edits are based on normal or average circumstances, sometimes the care provided for a patient may vary from the norm.

Given this possibility, there are several modifiers the medical provider can use to represent why or how service was provided. As with the prior edits, the provider’s medical record must contain information that supports the treatment given and the modifier used when billing. Documentation is vital to ensuring correct payment for medical services that were rendered.

In addition, to claim edits, the MAC utilizes a process known as the Medical Review Program. MACs perform data analysis to identify patterns in provider billing. If the MAC data analysis indicates that a provider-specific potential error exists, the MAC will review a sample of representative claims. This is called a “probe” sample. Usually, the sample is 20-40 claims.

If a medical provider receives a request for documentation under the Medical Review Program, this should raise a flag with the practice managers. Although it does not confirm that a problem or violation exists, it does confirm that Medicare has a suspicion that a problem exists and that they are looking into the issue further.

Great care should be taken in responding to this documentation request. The MAC is required to note on the request the reasons the claims have been targeted. The MAC must list the law, the NCD or the LCD that is the basis for the audit. In addition, the MAC should state what documentation is needed for the MAC to make their determination.

Severity of Error

When a MAC verifies that an error or problem exists with a specific medical provider through the review of sample claims, the MAC will classify the severity of the problem as minor, moderate or significant. There are several corrective actions that the MAC can take based on the severity of the problem. They are Provider Notification/Feedback, Prepayment Review and Postpayment Review.

If the error is minor, the MAC will notify the provider and inform the medical provider of the appropriate billing procedure. If the error is more severe, the MAC may opt to utilize Prepayment Review where a percentage of the provider’s claims undergo medical review before the MAC authorizes payment. If a physician or medical provider is subject to prepayment review, the provider may reestablish the practice of billing correctly and the prepayment review may be lifted. 

The MAC may also utilize Postpayment Review where statistically valid sampling is used to target claims. After a provider has been paid, the MAC may send out a request for documentation to support the medical services billed. If a medical provider receives either a prepayment or post-payment request for documentation, the provider has 45 days to respond. In a prepayment review, if the information is not received within 45 days, the claim will be denied.

In a post-payment review, an extension may be granted based on the volume of information that has been requested and the burden of submitting the requested information.

Again, documentation in a patient’s medical record is vital to avoiding further audit requests and denial of Medicare claims. Further, if a patient’s medical record does not support the services provided and billed, the medical provider or physician may be subject to a comprehensive Medicare fraud investigation and the case may be referred to law enforcement.

Turn to Chapman Law Group’s Medicare Audit Lawyers for the Expertise and Advice Your Health Care Practice Needs

Chapman Law Group’s Medicaid audit lawyers represent providers and suppliers nationwide during Medicare audits, recovery action, overpayment actions, secondary payer recovery, and Medicare appeals.

We represent providers and practices nationally during Medicare audits, Medicaid audits and third-party payor audits, such as MAC, ZPICRAC, Safeguard (PSC), and Comprehensive Error Rate Testing (CERT) audits.

The healthcare audit defense attorneys at Chapman Law Group work out of four national law office locations:

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