Medicare Administrative Contractor Audits and Appeals and How They Can Affect Your Practice

Medicare Administrative Contractor Audits and Appeals and How They Can Affect Your Practice

If you’re in medicine, you’re most likely aware of the role that Medicare Administrative Contractors play in the scheme of insurance claims. A MAC audit can mean damaging results for your practice if not handled correctly. Insurance and billing issues must be audited properly and use the regulations that were applicable at the time of submittal. All too often, errors and miscalculations figure into the damaging effects of a poor audit. Your practice can lose the ability to participate in government insurance provider programs that are a necessity to the business. Serious penalties are also levied and can lead to significant financial peril. If your practice has been advised of an upcoming audit or investigation or you’re currently experiencing this, you need a highly skilled healthcare attorney on your side.

The Auditing Process and its Effects

The goal of MACs is to prevent the government from fraud and abuse on behalf of Medicare. Since MACs also are considered the “hub” for the fee-for-service auditing under the direction of the Centers for Medicare and Medicaid Services (CMS), they have a big responsibility to uphold. More specifically, they’re responsible for reporting Medicare overpayments and to recoup monies paid from false and fraudulent claims submitted by providers. Any provider that bills for Medicare Part A and Part B, home healthcare and hospice service providers, and durable medical equipment providers, are all subjected to MAC audits.

Recordkeeping practices are scrutinized during a MAC audit and should be in good order and complete. The more questions the auditor poses will most likely lead to additional digging for information. Involving an attorney can potentially thwart or at least reduce the impact the auditors have on your practice. Often, the auditors themselves make mistakes or misapply newer regulations that are invalid. They’ll come to illogical and erroneous conclusions based on assumptions rather than facts. It’s also common for them to seek recoupment on items that aren’t within their scope of authority. A skilled attorney will essentially go over the auditors work and pose their own questions. Many times, this intervention can lead to a favorable outcome for the provider rather than continuing to be raked over the coals.

Potential Hazards of Not Handling a MAC Audit Properly

If a MAC audit produces results that allege fraud and abuse, serious consequences are likely to take place. Medicare fraud charges can have a very serious impact on the practice’s ability to bill for Medicare claims and require a prepayment review lasting up to 6 months. If severe enough, the provider may be ineligible to participate in any federal insurance programs. This can cripple a practice and lead to its demise.

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Legal Scenario: What Would You Do?

Scenario

Your medical practice just received a notice from a Medicare Administrative Contractor demanding repayment of $380,000 based on an audit of 30 patient claims, alleging improper billing codes and insufficient documentation for procedures performed over the past three years. The MAC has given you 40 days to respond or the overpayment determination becomes final and recoupment from future Medicare payments will begin immediately.

What are my options to fight this MAC audit determination, and how do I prevent them from withholding my future Medicare reimbursements while I appeal?

Attorney's Answer

You have the right to a multi-level appeal process under 42 C.F.R. § 405, starting with a redetermination request to the MAC within 120 days, followed by reconsideration by a Qualified Independent Contractor, and then a hearing before an Administrative Law Judge if the amount in controversy meets the threshold. Critically, you should file your redetermination request within 30 days of the overpayment demand to stop recoupment during the first level of appeal under 42 U.S.C. § 1395ddd(f)(2). We would also review every audited claim for proper documentation and coding accuracy, because MACs frequently apply overly aggressive extrapolation methodologies under the Medicare Program Integrity Manual that can be successfully challenged. An experienced healthcare fraud defense attorney can also evaluate whether the audit followed proper statistical sampling requirements and whether a targeted probe or full review is more appropriate for your case.

This is general information only. Contact us for advice specific to your situation.

Acting Against MAC Audits

Appeals and reconsiderations are a lengthy process that requires a considerable amount of time, money, and effort. It’s always best to avoid these things whenever possible. Attempting to handle the MAC audit or any legal claims that arise can be even more challenging and lead to significant [negative] outcomes. A skilled attorney can assess the level of threat that the practice may be exposed to and intervene properly. It’s even possible to avoid an unnecessary audit altogether if the audit is unwarranted or unjustified. Our offices have helped many clients in all aspects of healthcare law and defense matters. We’d be happy to review your case or any information you have about an upcoming MAC audit to see how we might be able to help. Get in touch with our offices by calling to schedule an appointment or contact us online, today!