Among its many provisions, the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) permitted the Centers for Medicare & Medicaid Services (CMS) to overhaul the Intermediary (Part A) and Contractor (Part B) systems, consolidating the two systems and centralizing the Medicare contractor system into a new system administered by Medicare Administrative Contractors (MACs) covering separate jurisdiction covering both Part A and Part B claims.
In consolidating the processing of Part A and Part B claims, many providers now submit Medicare audit claims denials to a new contractor for Redetermination appeal.. Additionally, in many jurisdictions, initial post-payment claims audits are now being conducted by Zone Program Integrity Contractors (ZPICs) rather than Program Safeguard Contractors (PSC). Together, newly-appointed MACs and ZPICs sometimes appear to be taking different approaches (from that of the provider’s previous contractors) when conducting Medicare audits.
MAC Program Benefits:
When first announced, there were a number of anticipated benefits that would result from the implementation of the consolidated, MAC approach to claims processing. These include, but are not limited to:
In consolidating existing systems, MAC are now responsible for:
o Enrolling health care providers/suppliers in the Medicare program.
o Educating providers about billing requirements.
o Handling claims appeals. (initial levels only)
o Answering provider inquiries directly.
o Answering beneficiary inquiries referred by the 1-800 MEDICARE call center.
Ongoing Concerns with the MAC Program:
While the consolidation of the Part A and Part B programs under a single contractor will hopefully result in significant cost savings and a more uniform approach to claims decision-making, a number of problems have been noted by providers we have worked with. Current concerns include:
Medicare Audit Appeal Recommendations:
Should you choose to handle claims appeals at the initial level (Redetermination) yourself, we strongly recommend that you check and see of the new MAC has issued any guidance covering the claims at issue. Carefully review both new and previous claims guidance, identifying possible errors made when the ZPIC conducted the initial claims review. Additionally, map out any and all arguments in support of payment. Finally, if you have not already done so, you will need to submit any documentation that will support the claims billed.
While you may prevail with regard to the claims at issue at the Redetermination level, more often than not, providers find that the claims denials are readily denied once again, often citing new, additional reasons for denial.
Don’t give up. Overall, we have found that the administrative appeals system does, in fact, provide most providers a fair opportunity to have their arguments heard.