Medicare Administrative Contractors – They do audits, too!

We hear a great deal about RAC audits, Medicaid Integrity Program audits, HEAT task force efforts, and other initiatives to reduce waste, fraud and abuse, but Medicare Administrative Contractors (MACs) do audits, too.

So if you are a physician and your MAC has sent you a request for medical records, what do you do?

First, take the request seriously!  MACs may select providers for medical review of claims based on several criteria:

  • They may be asking for records as part of the CMS CERT program, which looks at the MAC error rates in paying claims.
  • They may be reacting to input from other providers or patients, or from other government agencies involved in auditing or investigating fraud and abuse.
  • They may be using volume criteria, looking at physicians who are billing a high volume of claims.
  • They may have used data-mining techniques to look for unusual patterns of CPT codes billed.

Whatever the reason you have been identified for medical review, it is important to take the requests seriously as any Medicare audit should be, and to submit the records or other information timely – preferably as soon as possible.  The MAC will request information using some type of request form.  These forms should identify the patient by name, the date of service in question, and contain instructions on what records to send, where to send them and the time frames for submission.

My healthcare compliance consulting work has taught me a few lessons learned from interactions with Palmetto GBA, the MAC for J1 (California, Nevada and Hawaii) and J11 (Virginia, West Virginia, North Carolina and South Carolina):

  • Respond timely with the records requested because although the MAC may specify claims will be denied if the documentation is not received within 45 days, the actual date of processing for denial may be as short as 30 days.
  • Fax in the records and identifying forms, even if the request contains a PO Box or other address for mailing the records.  Most MACs scan the material received, and records sent via mail may not make it to the scanner.  Of course, records faxed in may not make it to the scanner, either, but at least you have some evidence of the date and time you faxed it in.
  • The initial provider-specific request is for a so-called Probe Sample, usually between 20 and 40 records, for inpatient or outpatient services.
  • Review the requests carefully since the MAC may request progress notes for inpatients on consecutive days of hospitalization.  Your local hospital that has to retrieve hand-written progress notes from the inpatient chart  will not appreciate being asked for entries from the same patient chart a day or two later.
  • Make sure the patient’s name is on each record or piece thereof that you send in, that the physician’s name is legible on the record, and the progress note or other report/note is signed.  Records with unclear documentation of the patient’s name or physician’s name/signature will likely lead to a denied claim.
  • Create your own log of the requests, and when/how you responded to them, and keep copies of the records you have submitted.

If the requests keep coming, especially if they are in excess of the initial Probe Sample, and come even before you have heard back on the results of the initial review, call and ask for information from the Medical Review department.  Sometimes the request process in the MAC’s system has gone into overdrive, and no one is monitoring the volume of requests going out to individual doctors.

If you are asked for a Corrective Action Plan, submit it on time, and make sure it addresses the issues identified by the MAC in its review.

It should go without saying that if you establish a comprehensive compliance program, especially one that includes critical internal reviews such as risk based coding and documentation audit, that you will not only fair much better in a medical review, but will be less likely to be audited in the first place.



When you need proven expertise and performance

Jim Hook, MPH

Mr. James D. Hook has over 30 years of healthcare executive management and consulting experience in medical groups, hospitals, IPA’s, MSO’s, and other healthcare organizations.