Lawyers for MAC Audits and Appeals

Medicare audits, recovery action and appeals are extremely common in the healthcare industry, and the attorneys at Norman Spencer Law Group have successfully handled it all. With more than a decade of experience in healthcare law, our attorneys have extensive knowledge of Medicare audits, including Safeguard, RAC and ZPIC audits. We’ve also helped numerous clients with issues that include secondary payer recovery, overpayment actions and appeals.

The Medicare Administrative Contractor, or MAC, is the program contractor tasked with processing and paying Medicare claims for a specific geographic area. In addition to identifying and correcting program overpayments and underpayments, these contractors are responsible for handling appeals from Medicare providers.

MAC uses a variety of tools to pinpoint improper claims, and one of them is prepayment edits. Prepayment edits are automated edits based on coding guidelines and input from the American Medical Association and other providers across the nation. The edits are often included in the licensed healthcare professional’s Medicare explanation of benefits. There are two types of edits MAC can use: NCCI edits and MUE edits.

National Correct Coding Initiative edits, or NCCI edits, are designed to promote proper coding methods and manage improper payments. That does not mean, however, that claims with edits are not payable.

As long as the services were appropriate based on the circumstances, and a proper modifier was used when the claim was billed, the claim may be eligible for Medicare payment. It’s up to the licensed healthcare professional to maintain medical records that contain information supporting the need for the service and the use of the modifier when billing.

Medical Unlikely Edits, or MUE, are meant to decrease improper payments. They do this by setting a maximum limit on daily services the average medical provider would render under normal circumstances for an individual patient.

As licensed healthcare providers know, services for patients may sometimes vary from the average or norm. When the scenario arises, healthcare practitioners can use several modifiers to indicate how or why the service was given.

It’s again up to the licensed professional to maintain records that support the treatment administered and the modifier used when submitting the bill. Proper documentation is crucial for receiving correct payment for medical services provided.

The Medical Review Program is another process MAC uses to review provider billing. Here the contractors analyze data to identify billing patterns. If the data analysis signals that a potential error exists with a specific provider’s billing, the contractors will review a sample of claims. This sample is known as a probe sample, and it usually consists of anywhere from 20 to 40 claims.

A request for documentation under the Medical Review Program is a red flag for practice managers. It lets managers know Medicare has a suspicion that an issue exists with a specific provider, and MAC is in the process of investigating it.

Responding to a request for documentation under the Medical Review Program requires exceptional care, and its best done with the assistance of an experienced healthcare attorney.

MAC’s request must include reasons a provider’s claims have been targeted, and MAC will also list the law, the national coverage determination (NCD) or the local coverage determination (LCD) on which the audit is based. The request will also outline what documentation is needed from the provider for MAC to make their determination.

Every time MAC verifies a potential problem exists with a specific provider after reviewing sample claims, it classifies the severity of the error as significant, moderate or minor. Corrective actions are based on the severity of the error. Options include provider notification and feedback, payment review and post-payment review.

Minor errors typically result in provider notification and feedback, which means MAC notifies the provider of an error and informs them of the proper billing procedure.

More severe errors often merit prepayment review, where a percentage of the provider’s claims are reviewed before MAC approves payment. Prepayment reviews can be lifted once the provider re-establishes correct billing practices. Post-payment reviews require healthcare professionals to send documentation to support billed medical services that have already been paid.

Prepayment or post-payment requests for documentation must be answered by the provider within 45 days. If information is not received within 45 days for a prepayment review, the claim will be denied. Post-payment reviews may be granted an extension, depending on the volume of information requested and the effort required to submit it.

It’s again up to the licensed professional to maintain records that support the treatment administered and the modifier used when submitting the bill. Proper documentation is crucial for receiving correct payment for medical services provided.

Maintaining proper patient medical records is once again vital for responding to MAC requests. Incomplete or inadequate responses can result in additional audit requests, denial of Medicare claims – or worse. If patient medical records don’t support the services rendered and billed, the licensed healthcare professional may become the target of a comprehensive fraud investigation and find their case referred to law enforcement.

If you find yourself or your practice targeted in a MAC audit, immediately contact the legal team at Norman Spencer Law Group. We can help healthcare professionals navigate through every stage of the process, protecting your practice, your reputation and your livelihood along the way. Call to schedule a consultation today.