Requesting a MAC Redetermination After a Medicare Audit
MAC Redetermination Team Lead
Former DOJ Attorney
Contact Lynette 
MAC Redetermination Team Lead
Contact Nick Medicare audits frequently leave participating providers facing substantial recoupment liability based on billing errors or improper payments. In some cases, these audits result in denying pending Medicaid claims on Medicare and Medicaid programs, prepayment review and post-payment audits, and other consequences. If your healthcare practice or durable medical equipment business faces any consequences, your next step may be to file an appeal.
The unfortunate reality is that Medicare auditors frequently make mistakes. Despite the important role auditors play in the Medicare system and the severe consequences that inaccurate audit results can have for participating Medicare or Medicaid providers, Medicare auditors are not always (or even often) as careful as they should be. From applying outdated billing regulations to making flawed assumptions and overlooking relevant data, numerous mistakes can leave providers facing unwarranted consequences.
This is when the Medicare audit appeals process comes into play.
Medicare Audit Appeals: A Brief Introduction to the Process
While the Centers for Medicare and Medicaid Services (CMS) gives its recovery audit contractor substantial authority and leeway to conduct audits, it also recognizes the possibility that these contractors will make mistakes. To ensure that Medicare-participating providers are not subjected to unwarranted recoupments and other unwarranted penalties, CMS and the recovery audit program allows providers to file appeals.
Under its Medicare program audits, CMS has established a five-stage appeals process. Providers who need to challenge the outcomes of their audits must pursue these stages in order (until they achieve a satisfactory result). The five stages of Medicare audit appeals are:
- Medicare Administrative Contractor (MAC) redetermination
- Qualified Independent Contractor (QIC) reconsideration
- Office of Medicare Hearings and Appeals (OMHA) decision
- Administrative review by the Medicare Appeals Council
- Judicial review in U.S. District Court
What can Medicare-participating healthcare providers expect from this process? The short answer is, “It depends.” If an auditor’s determinations are clearly unwarranted, then it should be possible to secure a reversal at the MAC redetermination stage—assuming a provider initiates its appeal in time. However, for various reasons, this doesn’t always happen. It is not unusual for providers to need to go through multiple stages of Medicare audit appeals to achieve a just result. While this is also unfortunate, this is another reality of our current Medicare system.
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55th Speaker, U.S. House of Representatives (ret.)
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Former U.S. Secretary of State
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Former Supervisory Special Agent (FBI)
MAC Redetermination: The First Step for Challenging Flawed Medicare Audit Findings
Regardless of the circumstances at hand, the first step toward successfully challenging a flawed Medicare audit determination is to request a MAC redetermination. This is true even if a MAC conducted the audit at issue (i.e., a Targeted Probe and Educate (TPE) program audit). Here is what Medicare-participating healthcare providers need to know about requesting a MAC redetermination:
1. The Deadline for Requesting a MAC Redetermination
One of the most important pieces of information for healthcare providers that must challenge the outcome of a Medicare audit is the deadline for requesting a MAC redetermination. Once this deadline passes, providers can lose their ability to file an appeal. As CMS explains:
“The appellant (the individual filing the appeal) has 120 days from receipt of the initial claim determination to file a redetermination request. The notice of initial determination is presumed to be received 5 calendar days after the date of the notice unless there is evidence to the contrary.”
As a result, providers have 125 calendar days from the date of their Medicare Summary Notice (MSN) or the date of their remittance advice disclosing the audit’s findings in most (but not all) cases. Once again, missing this deadline—even by a single day—can result in loss of the ability to seek a MAC redetermination (though there are exceptions for “good cause” and certain other circumstances).
Of course, providers do not have to wait this long, and, in most cases, it will make sense to take action promptly. Not only will this help avoid any questions about timeliness, but it will also help ensure that the audit process moves as efficiently as possible as well. Initiating a MAC redetermination promptly can also keep the relevant issues fresh in everyone’s minds, which can help with avoiding unnecessary confusion and delays as well.
2. The Process for Requesting a MAC Redetermination
Requesting a MAC redetermination starts with preparing and filing form CMS-20027 (“Medicare Redetermination Request Form – 1st Level of Appeal”). Along with identifying information, providers must also list the specific claims they seek to appeal and explain why they disagree with their audit determination. Providers can attach additional sheets as necessary; CMS also explains that “[t]he appellant should include with their redetermination request any and all documentation that supports their argument against the previous decision.” Examples of supporting documentation that may be necessary include:
- Billing records
- Patient records
- Medical necessity determinations
- Coverage determinations
- Liability limitations and other relevant documents and forms
Medicare-participating providers can challenge any or all determinations made during an audit. If a provider disagrees with only a portion of the audit contractor’s findings, then the provider can specifically target these findings in its request for redetermination.
3. Waiting for the MAC’s Decision (or “Redetermination”)
Unlike future Medicare audit appeals process stages, MAC redeterminations are largely unilateral procedures. In other words, once providers submit their redetermination requests, they have few (if any) opportunities to play an active role in the process—although experienced legal counsel may be able to engage with the MAC during its redetermination to address any ambiguities, questions or concerns. With this in mind, giving due time and attention to preparing the redetermination request is extremely important, as the request and supporting documentation will generally form the basis for the MAC’s decision.
CMS’s Medicare Claims Processing Manual is publicly available online. Section 310.4 of the Manual provides an overview of how MACs are supposed to evaluate requests for redetermination. Among other things, Section 310.4 states:
- “The redetermination is an independent review of an initial determination. The individual performing the redetermination must not be the same person who made the initial determination.”
- “The contractor reviews the evidence and findings upon which the initial determination was based, and any additional evidence the parties submit or the contractor obtains on its own.”
- “The contractor should review all aspects of the claim or line item necessary to respond to the appellant’s issue. For example, if the appellant questions the amount paid, the contractor must also review medical necessity, coverage, deductible, and limitation on liability, if applicable.”
Despite these protections, it is not unusual for MACs to reach flawed conclusions during the redetermination process—even when a provider has submitted all information necessary for correct conclusions. It is also important to note that MACs can “dismiss” redetermination requests outright based on technical deficiencies, and when this happens, providers have six months after receipt of the dismissal notice to request that the MAC vacate the dismissal based on “good and sufficient cause.”
4. Reviewing the MAC’s Conclusions
In most cases, a MAC must issue a redetermination letter within 60 days of receiving a provider’s request for redetermination. As explained in the Medicare Claims Processing Manual:
- “For unfavorable redeterminations, the contractor mails the decision letter to the appellant, and mails copies to each party to the initial determination (or the party’s authorized representative and/or appointed representative, if applicable).”
- “For partially favorable redeterminations, the contractor mails and/or otherwise transmits the decision letter, and an adjusted MSN or RA to the appellant. The contractor mails a copy of the decision letter and mails or otherwise transmits an adjusted MSN or RA to each party to the initial determination (or the party’s authorized representative, if applicable).”
- “For fully favorable redeterminations, the contractor mails or otherwise transmits an MSN or RA reflecting the adjustment action to each party (or the party’s authorized representative, if applicable) on the next scheduled release.”
Unless a redetermination is fully favorable, healthcare providers should carefully review the MAC’s conclusions upon receipt. If pursuing the next stage in the Medicare audit appeals process is warranted, strict deadlines also apply here.
5. Evaluating and Pursuing Next Steps
In all cases, after receiving a MAC redetermination, healthcare providers should thoughtfully evaluate their next steps with the help of their Medicare compliance counsel. Is another appeal warranted? Are updates to the provider’s Medicare billing compliance documentation necessary? Are updates to its billing processes and protocols necessary? These questions (among others) require informed decision-making. Regardless of a provider’s Medicare billing history, compliance going forward is essential, and providers must ensure that they are not continuing to put themselves at risk while pursuing Medicare audit appeals.
Discuss Your MAC Redetermination Request with a Medicare Appeals Lawyer at Oberheiden P.C.
Do you need help deciding whether to file a MAC determination request? Do you need help responding to a MAC redetermination? If so, we encourage you to contact us promptly for more information. To schedule a complimentary consultation with a Medicare appeals attorney at Oberheiden P.C., please call 888-680-1745 or tell us how we can help online today.
