Between 2011 and 2012 the number of audits by Medicare Administrative Contractors (MAC) went up by 700%. This rise in audits by 700% “do not include the reviews performed by the three legacy contractors that continue to provide claims administration services”. So this means, the number is even greater.
Knowing the role of these different auditors is crucial:
- Medicare Administrative Contractors (MAC) – (1) process and pay claims; (2) conduct pre- and postpayment claims reviews; (3) recoup overpayments; (4) remediate underpayments.
- Zone Program Integrity Contractors (ZPIC) – perform pre- and postpayment claims reviews (looking for fraud).(*)
- Comprehensive Error Rate Testing (CERT) contractors – conduct postpayment claims reviews on a random sample of claims processed by the MACs (to estimate Medicare improper payment rate).
- Recovery Auditors (RA) – (1) conduct data analysis; (2) conduct postpayment claims reviews,
The data was collected by the GAO which argued that inconsistencies between the different programs demand that some attempt be made to harmonize the rules and processes.
Reference: Report to Congressional Requesters, Medicare Program Integrity: Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency. GAO-13-522. (Washington, D.C.: Government Printing Office, July 2013).
Note: (*) The Zone Program Integrity Contractor (ZPIC) companies are (1) Safeguard Services (SGS); (2) AdvanceMed; (3) Cahaba; and (4) Health Integrity.