Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), Zone Program Integrity Contractors (ZPICs), commercial insurance companies, and Medicare Advantage Plan Special Investigative Units (SIUs) routinely identify and scrutinize providers and suppliers suspected of inappropriate or excessive billing of services or supplies. Prepayment reviews are often disruptive to medical practices and routinely result in cash flow being severely reduced or delayed. Ill-trained or inexperienced auditors frequently render negative decisions that can only be resolved by filing appeals, which are time consuming and result in the unwarranted stress and waste of your staff’s time.
Prepayment review is not terminated until the provider or supplier has improved the billing accuracy percentage significantly. This can be a daunting task because the auditors rarely provide specific feedback to justify the denial rationale.
MCA’s specialists are comprised of Certified Professional Coders (CPCs) with review experience in all medical specialties and are members of the American Academy of Professional Coders. MCA’s specialists evaluate each reviewed claim to ensure the documentation establishes medical necessity for all the services and supplies. The CPT codes and ICD-10-CM codes are evaluated and the modifiers verified to ascertain their validity. MCA’s specialists also use Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) to influence their decisions for Medicare Part B claims. When applicable, Medicare Advantage Plan and commercial insurance company websites are accessed to locate any applicable medical review policies that need to also be considered.
MCA’s unparalleled success in defending health care providers and suppliers of all specialties in retrospective payment audits and prepayment reviews is invaluable in providing the necessary education to convince even the most aggressive insurance auditor that the services were medically necessary and billed appropriately.
