Medical Business Office, Inc. is a Professional Medical Billing Service providing end-to-end Revenue Cycle Management Services to Physicians and Facilities since 1985!  It’s part of “what we do” to be active members of industry related organizations in order to stay on top of revisions, compliance, regulations as well as proposed and upcoming change considerations in all aspects of our clients’ interests.  This involves having a voice in Washington on your behalf.

Today, MBO would like to share with you the information learned from one of our organization’s known for keeping us “in the know”.  HBMA, is an organization designed for billing services, touching on all core billing matters including governmental relations.

I am taking one, of many, articles shared with HBMA members, regarding CMS’ recent changes on how your MAC Audits Provider’s Claims.

CMS Makes Changes to How MACs Audit Provider’s Claims
The Centers for Medicare and Medicaid Services (CMS) is taking steps to require Medicare Administrative Contractors (MAC) to provide education to providers on incorrect claims before referring those providers to other program integrity contractors.

The Provider Compliance Group (PCG) is the office within CMS responsible for this new approach, called “Targeted Probe and Educate.”

The HBMA Government Relations Committee met with PCG staff during its June visit to CMS headquarters in Baltimore, MD. PCG staff presented on TPE during that meeting.

Under this new program, when conducting an audit, MACs will randomly select between 20 and 40 claims from a provider. MACs are supposed to target only the providers who have the highest claim error rates compared to their peers. After selecting the claims, which are fewer than MACs have been allowed to select in the past, the MACs are required to provide education to the provider on the incorrect claims it identified through the audit.

MACs must conduct three rounds of these audits before they can refer a provider to one of CMS’ other program integrity contractors such as Recovery Audit Contractors (RAC), or Zone/Unified Program Integrity Contractors (Z/UPIC).

This new program reflects the PCG’s goal of reducing the administrative burden of audits on providers and targeting the few bad actors in the program while sparing the majority of providers who are compliant with Medicare billing policies.

MACs are only one piece of a larger Medicare program integrity contractor framework. CMS is also making reforms to the RAC program which perform post-payment reviews of Medicare claims. CMS is requiring RACs to facilitate a discussion period with the provider to discuss the RAC’s findings and allow the provider to submit a corrected claim before the RAC takes action against the provider. Allowing the provider to submit a corrected claim is something HBMA has been promoting to CMS for several years.

These reforms will hopefully help alleviate the growing backlog of appealed claims pending before the Department of Health and Human Services (HHS). Most of these appeals are for hospital inpatient status determinations that were challenged by RACs. However, the backlog also affects other providers who want to have their appeal resolved quickly so that they can resubmit a claim within the one-year timely filing deadline after the appeal determination.

Medical Business Office, Inc. takes great pride in exhausting every level of appeal necessary to insure our clients are paid for the service they provide.  Likewise, we are dedicated to passing on the education to our clients so as to keep them in compliance with all payers, including governmental agencies.

If you haven’t been able to keep up with all the changes, or you aren’t sure you’re in compliance, or if you would just feel better knowing you can concentrate on patient care while MBO takes care of the rest, give us a call at 573.634.7155.  We provide Professional Medical Billing Services with end-to-end Revenue Cycle Management Services for our clients’, in turn our clients reap the benefits of peace of mind, knowing they are in compliance.