(July 5, 2012): Recently, the Centers for Medicare & Medicaid Services (CMS) has done some realignment of its Medicare Administrative Contractor (MAC or AC) jurisdictions for Medicare Parts A and B. In addition, it has actively sought proposals through a competitive bidding process to get the most cost-effective contractors processing Medicare claims. Because of all of these changes, it can be confusing for affected providers to know which contractors are coming or going. In addition, it is important to keep in mind that the transition of MACs can create problems and inconsistencies in claims processing and Medicare post-payment appeal issues. As MAC changes take place, it is important that you review the MAC's guidance and ensure that your documentation, medical necessity, coding and billing requirements are being met
I. Recent MAC Changes:
The most striking change over the past several months has been the transition of MAC Jurisdiction H (Texas, Oklahoma, New Mexico, and Colorado) from TrailBlazer Health Enterprises to Highmark (Novitas Services). TrailBlazer recently lost its bid protest to retain the contract for this jurisdiction. During the transition period, providers in Jurisdiction H should carefully inspect all remittance notices and explanation of benefits forms to ensure that billing, coding, and payment functions continue as expected. In addition, providers appealing Medicare audit results by Health Integrity (the Zone Program Integrity Contractor (ZPIC) for this region) should seek legal advice when filing redetermination appeals, as it may not be obvious to whom an appeal should be sent. Sending the appeal to the wrong location could negatively affect your appeal rights, especially if you are close to the appeal deadline of 120 days.
Last year, CIGNA Government Services lost its contract for many East Coast States, such as North and South Carolina, to Palmetto GBA. While much of this transition was smooth, we have seen instances when appeals information and repayment information related to Medicare post-payment audits was not correctly sent from one contractor to the other. This has resulted in significant time and expense in “putting the pieces back together” when trying to get CIGNA to review its old files and simultaneously identifying what information Palmetto actually does have. Nevertheless, with perseverance, it is possible to recreate a record of payment information during the transition period. Keep this in mind if you are in the middle of an audit with any of these contractors.
II. Possible Contractors We Will See After the Consolidation:
Finally, CMS is planning on further consolidating all of the Part A and B MACs from 15 right now to just 10 in 2016. While no one knows for sure who will win each contract, expect some of the bigger names now processing claims to win those contracts in the future. These may include:
- Palmetto GBA
- Novitas (Highmark)
- National Government Services (NGS)
- Wisconsin Physician Services (WPS)
- First Coast Service Options (FCSO)
Call us for additional information on current MAC contract awards, bid protests, and possible restructuring of the MAC system.
It is important for providers and their office managers to keep alert when seeing anything from a MAC. In addition to processing claims, MACs conduct re-determination appeals and may also initiate their own audits of a provider’s claims. While these are usually on a smaller scale than ZPIC audits, they often act as a precursor or probe audit before receiving a much more expansive – and potentially damaging – audit from a ZPIC. As such, it is important to fight these smaller audits as well.
Robert Liles is the managing member of Liles Parker PLLC. Located in our Washington, D.C., office, Robert represents providers in Medicare post-payment audits and appeals, and similar appeals under Medicaid. In addition, Robert counsels clients on regulatory compliance issues, performs gap analyses and internal reviews, and trains healthcare professionals on various legal issues. For a free consultation, call Robert today at: 1 (800) 475-1906.