AbnerHoward
10-03-2024, 06:05 AM
Medicare Administrative Contractor (MAC) audits are invasive and time-consuming events that can lead to substantial financial liability for healthcare providers. Mistakes by auditors and healthcare provider personnel can lead to costly consequences. Therefore, providers need to take a comprehensive approach to defend against MAC audits with the goal of preventing further federal inquiry.
Medicare Administrative Contractors (MACs) are, “private healthcare insurer[s] that ha[ve] been awarded a geographic jurisdiction to process Medicare Part A and [B] medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.” They play several roles within the Centers for Medicare and Medicaid Services’ (CMS) “fee-for-service” audit recovery program, which reviews the functions of the Medicare and Medicaid programs, one of which includes auditing Medicare Part A and B reimbursement claims, Medicare claims submitted by DME companies, and Medicare claims from home health and hospice service providers.
During an audit, MAC auditors will review a provider’s Medicare billing records, and part of their audit requests may be to speak with certain employees. Once they have spent time reviewing claims and reviewed the information solicited, they will issue a finding that either: (i) the provider’s billings are accurate, (ii) the provider has underbilled Medicare and is entitled to additional reimbursement, or (iii) the provider has overbilled Medicare and is liable for recoupments.
Most audit determinations fall into the third category. In many cases, a healthcare provider’s alleged recoupment liability will be substantial. Under the fee-for-service model, MACs and other CMS audit contractors have a financial incentive to recover recoupments, and data from recent years indicate that audit contractors seek to recoup far more than they determine needs to be reimbursed. While some providers undoubtedly make mistakes that result in overbillings (and cases of intentional Medicare fraud (https://federal-lawyer.com/healthcare-defense/) are the exception to the norm), in many cases, substantial demands for recoupment are the result of errors during the auditing process.
Medicare Administrative Contractors (MACs) are, “private healthcare insurer[s] that ha[ve] been awarded a geographic jurisdiction to process Medicare Part A and [B] medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.” They play several roles within the Centers for Medicare and Medicaid Services’ (CMS) “fee-for-service” audit recovery program, which reviews the functions of the Medicare and Medicaid programs, one of which includes auditing Medicare Part A and B reimbursement claims, Medicare claims submitted by DME companies, and Medicare claims from home health and hospice service providers.
During an audit, MAC auditors will review a provider’s Medicare billing records, and part of their audit requests may be to speak with certain employees. Once they have spent time reviewing claims and reviewed the information solicited, they will issue a finding that either: (i) the provider’s billings are accurate, (ii) the provider has underbilled Medicare and is entitled to additional reimbursement, or (iii) the provider has overbilled Medicare and is liable for recoupments.
Most audit determinations fall into the third category. In many cases, a healthcare provider’s alleged recoupment liability will be substantial. Under the fee-for-service model, MACs and other CMS audit contractors have a financial incentive to recover recoupments, and data from recent years indicate that audit contractors seek to recoup far more than they determine needs to be reimbursed. While some providers undoubtedly make mistakes that result in overbillings (and cases of intentional Medicare fraud (https://federal-lawyer.com/healthcare-defense/) are the exception to the norm), in many cases, substantial demands for recoupment are the result of errors during the auditing process.