What’s the difference between a MAC and a RAC?

When it comes to protecting Medicare dollars, they share the responsibility of ensuring healthcare providers are paid correctly for services provided, and both conduct audits to help ensure as much.

But once a MAC audits a service, a RAC cannot. And visa versa. So does that mean there might be a little friendly competition between them?

Deborah K. Hale, CCS, president and CEO of Administrative Consultant Service, LLC, who spoke during the August 13 audio conference, “Inpatient vs. Observation Service: Level of Care Compliance in a Challenging Regulatory Environment,” said she’s seeing a little bit of competition between MACs and RACs across the country. “We’ll have to see how this pans out,” she said. “But since those agencies do have the same responsibility, we may see more activity from the MACs than we do from the RACs.”

TrailBlazer, a MAC for Hale’s home state of Oklahoma, conducted an audit of 250 inpatient discharges for MS-DRG 247 (the DRG for coronary artery drug-eluting stent without a secondary diagnosis that counts as a major complication/comorbidity), according to a TrailBlazer Job Aid.

 

There was a 98.8% level of care error rate, according to the audit, meaning TrailBlazer recouped reimbursement in 98% of cases. “For most hospitals, that amount is in the $12,000 range,” Hale said. “That’s a pretty nice slice of reimbursement, and that leaves the hospital having to donate that drug-eluting stent at no charge.”

 

(The MAC denied 87% of the cases because it believed the provider should have performed the procedure in an outpatient, rather than inpatient setting. Another 11% were denied because providers didn’t submit requested medical records.)

 

And that’s not all. During a recent HCPro focus group call, one healthcare provider recently reported seeing a 70% increase in audit activity by commercial payers at their facility.

 

Just what every provider wants—more audits.

 

A: Regardless of the type of RAC review, you may appeal a RAC denial or recoupment if you believe the denial is not warranted Many of the automated reviews focus on billing rules, such as maximum units per day, so even if additional units seem appropriate, billing rules reign.

 

However, it may be worthwhile to appeal a claim when the effective date of a rule causing the denial is different than the date services were rendered. For example, consider local and national coverage determinations. A recoupment today based on current guidelines may not have been in effect when the patient received the service. If you are aware of this date discrepancy, consider appealing and include in your appeal documentation the effective date of that medical policy.

 

Hospitals’ awareness of the importance for timely and comprehensive documentation (especially physician documentation) to prevent and overturn denials has escalated over the past few years. It is common today to find hospital's implementing in-hospital documentation programs. Those hospitals that have deployed such programs have found improved documentation compliance and are better equipped to provide a defensible response when reimbursement is challenged.