Understanding MAC Audits in Home Health: A Q&A Guide
Medicare Administrative Contractor (MAC) audits can be a daunting prospect for home health agencies. To shed light on this process, we've compiled a Q&A based on insights from Annette Lee of Provider Insights, an expert in home health and hospice reimbursement.
What are MAC audits?
MAC audits are part of a process called Targeted Probe and Educate (TPE). These audits examine claims to ensure compliance with Medicare requirements and can significantly impact an agency's operations.
How often do MACs conduct audits?
While not all providers are subject to frequent audits, when they occur, they can be intense. Typically, 20 to 40 claims are selected for review, which can be a substantial burden, especially for smaller agencies.
How are agencies selected for audits?
Selection is data-driven. Agencies that stand out from the average in terms of billing patterns, length of stay, top diagnoses, or case mix may be chosen for audit. The goal is to understand why an agency differs from the norm.
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Can agencies prevent being targeted for audits?
While there's no guaranteed prevention, agencies can mitigate risk by monitoring their PEPPER (Program for Evaluating Payment Patterns Electronic Report) report. This free annual report compares an agency's data to national, state, and jurisdictional averages.
What do auditors look for during a MAC audit?
Auditors focus on the conditions of payment outlined in the Medicare Benefit Policy Manual. Key areas include:
Valid face-to-face visits
Technical requirements
Patient homebound status
Necessity of home care
How can agencies prepare for audits?
Regularly review PEPPER reports
Stay within the 80th percentile for various metrics
Ensure documentation supports billing practices
Familiarize staff with the Medicare Benefit Policy Manual
What happens during a TPE audit?
Agencies receive notification of selection for TPE. Claims are then suspended, and agencies must provide documentation through the MAC portal. The review process typically takes about 30 days.
By understanding the audit process and maintaining thorough documentation, home health agencies can better navigate MAC audits and ensure compliance with Medicare requirements.
Steps for Responding to Unfavorable MAC Audit Findings:
Strengthen your agency's audit readiness! Partner with HealthRev Partners and Provider Insights for expert guidance on Medicare compliance and documentation.
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