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Explore This IssueJune 2013
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- E: All of the above.
- MACs are Medicare carriers. These carriers are contracted by the government to administer healthcare benefits to Medicare-eligible patients. An insurance carrier may become a MAC by bidding for the contract. Each MAC is assigned a territory that covers multiple states.
- RACs are third-party auditors created and hired to locate and recover improper Medicare payments made to eligible providers under the Medicare fee-for-service Part B plan. RACs began as a demonstration program in California, New York, and Florida in 2005, which was expanded to cover Massachusetts and South Carolina in 2007. By the end of the demonstration program in 2008, the RAC had recovered more than $900 million in overpayments that were returned to Medicare. In addition, $38 million of underpayments were returned to providers. The program is now permanent as it has proven successful in recouping payments. The RAC receives a fee for any improper payments recovered.
- ZPICs are not limited like RACs. ZPICs can audit all types of Medicare claims: Medicare Part A, home health, hospice, durable medical equipment, Managed Care Part C, and Medicare Part D prescription drug claims. While RACs are looking for improper coding, ZPICs are looking for fraud. Like the RACs, ZPICs are third-party contractors that receive a fee for any recovered improper payments.
- The OIG’s mission is to protect the integrity of programs administered through the Department of Health and Human Services, as well as the health and welfare of program beneficiaries. The OIG has the authority to impose both monetary and criminal penalties. They will investigate both health providers and insurance carriers.
- B: False. Below are the limitations:
- Ten medical records per 45 days for solo practitioners (per NPI number);
- Twenty medical records per 45 days for practices with two to five individuals (NPI number);
- Thirty medical records per 45 days for practices with six to 15 individuals (NPI number); and
- Fifty medical records per 45 days for practices with 16 or more individuals (NPI number).
- B: If a ZPIC representative visits a practice and requests access to medical records and the practice refuses, the agent will leave, but the provider’s NPI number will be suspended until the provider complies with the request. Keep in mind that if a ZPIC contacts or visits a practice, it suspects fraud in the practice. It is important for all practices to have a compliance plan in place for dealing with all audit requests and visits by auditors.
- B: False. That would be double jeopardy. Once a claim has been audited by another agency, that claim cannot be audited again.
- A: There are five steps to an appeal process:
- Redetermination by the Medicare payment processor (fiscal intermediary, carrier, or MAC). An individual, provider, or supplier must file an appeal within 120 days of the initial decision on a claim.
- Reconsideration by a Qualified Independent Contractor (QIC). An individual, provider, or supplier must file an appeal within 180 days of the redetermination. The QIC must issue its decision within 60 days.
- Hearing by an Administrative Law Judge (ALJ). An individual, provider, or supplier must file an appeal within 60 days of the QIC’s reconsideration, provided that the case involves at least $130 in dispute. The ALJ must issue a decision within 90 days.
- Review by the Medicare Appeals Council within the Departmental Appeals Board. An individual, provider, or supplier must file an appeal within 60 days of the ALJ’s decision, provided that the case involves at least $130 in dispute. The Medicare Appeals Council must issue an appeal within 90 days.
- Judicial Review in U.S. District Court. An individual has 60 days to file for judicial review, provided that at least $1,260 remains in dispute.