According to a recent Centers for Medicare and Medicaid Services (CMS) MLN Connections, Medicare Administrative Contractors (MAC) are beginning to conduct post-payment medical reviews for dates of services (DOS) after March 2020.  After a pause in audits due to the COVID-19 pandemic, the MACs already did resume audits on post-Payment items or services before March 2020. The goal of the MAC audit is to prevent the government from fraud and abuse on behalf of Medicare. Go to the following link to learn more: 2021-06-03-MLNC | CMS

Ask yourselves if you have a contact and/or a good relationship with your MAC, as this will definitely be helpful. Remember that if the MAC continues to find improper payments after three (3) rounds of Target Probe and Educate (TPE), they can put your facility or a specific provider under 100% prepay review, or extrapolation or make a referral to Recovery Audit Contractors (RAC) or take other action.

Keep in mind that if the MAC auditors are unable to make a determination on prepayment or post-payment claims review based on the information that’s been provided, they will issue an additional documentation request (ADR) to solicit supporting documentation. So, this means we need to always review the medical documentation in addition to the code assignments.

We are now approaching the mid-point of the year and it’s the perfect time to assess your own audit plan and if you’ve already conducted some inpatient and outpatient audits, you should assess your next steps and corrective action.  Determine if additional audits are needed that focus on the issues identified and also conduct education regarding the audit findings to help with increased understanding and compliance of the documentation and coding requirements. When you conduct education be sure to include educating your providers also.

In this same MLN from June, CMS cited a recent OIG (Office of Inspector General) report that determined there were improper payment for outpatient Intensity Modulated Radiation Therapy (IMRT).  In particular hospitals were found to be billing separately for complex stimulations that are really a part of the IMRT planning. So, this is another area that your organization, healthcare system or hospital should be auditing.

In addition, to prepare for the MAC audits, be sure to contact your external consulting firm regarding documentation and coding audits they can perform. Add to this a strong and robust appeals process to assist with any MAC denials.

Another resource to review regarding MAC audits is the “MACs Resume Medical Review on a Post-Payment Basis,” MLN Connect eNews, CMS, August 6, 2020, https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-08-06-mlnc#_Toc47449031.

Written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

Reimbursement Management Consultants (RMC) can provide assistance with medical coding support, auditing, education, compliance consulting, and HCC/risk adjustment services. RMC is a woman-owned, US-based and operated company which specializes in a variety of medical coding and auditing services. Contact us here.