Revenue Cycle

MACs vs. RACs: Could a little friendly competition mean more bad news for healthcare providers?

The RAC Report, September 3, 2009

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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.
 
Editor’s note: We would also like to take a moment to welcome Deborah K. Hale, CCS, president and CEO of Administrative Consultant Service, LLC to the RAC Report Advisory Board.



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