The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) was created to improve Medicare law and benefits by reducing administrative problems and modernizing the system. To support this process, Medicare Part A Fiscal Intermediaries (FIs) and Part B Carriers are replaced by MAC under the mandate of MMA. MACs now process Medicare claims and are the primary operational contact between the Medicare Fee-For-Service program, and approximately 1.5 million health care provider enrollees. MACs work to enroll and educate health care providers on the Medicare program and billing.
There are currently 15 Part A/Part B MAC jurisdictions. Providers and suppliers are generally assigned to a MAC based on geographic location. However, large chain providers are permitted to request the opportunity to consolidate their billing activities under MAC with jurisdiction over the chain’s home office. Also, a provider-based entity (e.g.., Hospital-based SNF) is assigned to the MAC that covers the state where the main “parent” provider is assigned.
The MAC process consists of analyzing claims data, evaluating information, and identifying suspected billing problem areas. Based on the severity, identified problem areas are targeted for review. A sample of the claims is used to verify that an error exists and a contractor then classifies the severity of the problem as minor, moderate, or significant. Moreover, MACs can review pre-payment and post payment.
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What does a MAC do?
- Perform claims-related activates and establish relationships with providers;
- Performs all services in accordance with the law
- Coordinates activities with CMS and other agencies;
- Determines whether the claim should be paid
- Calculates payment amounts and remits these payments to the appropriate party;
- Enrolls new providers;
- Conducts redetermination on appeals for claims;
- Operates a Provider Customer Service Program to educate providers;
- Responds to provider telephone and written inquiries
Level of MAC review
- Usually the MAC deals with minor or isolated billing issues through provider notification or feedback with reevaluation after notification.
- For serious problems, the MAC has the authority to review claims on a prepayment basis
- Usually at the MAC level of review, it is still a “mistake” v “fraud”
- MACs do have the authority to do prepayment and reviews, which are always more difficult for the provider
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