The Medicare Administrative Contractor (MAC) is a new contract reform project thatwill enhance the flow of data for services charged to Medicare. Under the old structure, Part B Medicare (physician service payment) and Part A Medicare (hospital and other facility payment) were administered by separate private contractors. Under the new system, a MAC will process and pay both Part A and Part B claims for a given area. This process will allow the carrier to quickly crosscheck hospital/facility charges and physician charges to be sure that the Medicare payments for a given patient are appropriate.
With MAC contract reform, Medicare is simplifying and centralizing contracting and data collection and payment functions in the entire Medicare system. Under the new program, there will be 15 MAC jurisdictions that will include Parts A and B (as shown in the accompanying map) and four specialty MACs for the administration of durable medical equipment and hospice, further simplifying the administration of the Medicare payment system. Each of these Part A/B areas is referred to as J plus a number, 1 through 15 (eg, J4). The four specialty MACs will be referred to as JA, JB, JC, and JD. Each area contains multiple states, which are awarded in separate contracts. In this article, we will focus only on Part A and B MACs.
The Centers for Medicare & Medicaid Services considers Medicare contracting reform, which can be found in sections 9 through 11 of the Medicare Prescription Drug Improvement and Modernization Act of 2003, a major component of its move to be more successful in administering Medicare fee-for-service contracts. Why does Medicare look at this as such a big part of its future success to ensure health care security for Medicare beneficiaries? The answer is quite simple. There was very little data exchange between Part A and Part B payers. Originally, there were different contractors for Part A and Part B in each state. Over the past several years, there has been a consolidation of contracts, with a single contractor administering several different states for Part B Medicare. In addition, some of the same carriers had been awarded contracts to administer Part A Medicare, but not necessarily in the same states in which they were assigned the Part B contract.
The MAC program consolidates this process further, requiring the same contractor to administer the Part A and Part B programs for a group of states in a given region.
The contract awards began in 2005 and will continue through 2009. As of this writing, all jurisdictions have been awarded for Parts A/B except 8, 9, and 10, which are scheduled to be awarded in September 2008.
Although they have encountered a few bumps in the road, the MACs are beginning the process of operation. The Part A/B MACs are required to develop an integrated and consistent approach to medical coverage across the service areas that benefits both beneficiaries and providers.
How do you fit in?
Why is this important to your practice? First and foremost, it means that most states will change carriers. Your current electronic submissions will have to be modified to communicate with the payment system of your new carrier. In addition, you’ll likely need to re-apply and re-qualify for electronic payments.
Your local carrier decisions may be modified, since all payment policies will be standardized across all states involved in that particular MAC jurisdiction. Thus, you will need to review local coverage decisions and get acquainted with a new medical director.
Even more important over the long run, the same carrier will now have all payment data from Medicare patients in one data system. It will be easier to detect any inconsistent billing for any given patient in a given area. This will force physicians to be very accurate in their coding, and diagnoses will need to coordinate with those of hospitals. If a hospital has used a separate diagnosis to obtain an increased payment over what your documentation and charges indicate for that patient, then that discrepancy probably will be evaluated. The combined data can also be used to increase checks and balances that can be used for quality measures.
You will also notice change in support. For instance, in Jurisdiction 4 the Noridian payment offices in Colorado are being closed down and Trailblazer does not intend to have an office in Colorado. All payments will be handled in Trailblazer’s Texas location. Your office will likely have to establish new contacts within the provider relations department as well as technical assistance personnel.
The Carrier Advisory Committees may or may not be continued in the same mode that they have been, and you may notice other changes as well. For example, Trailblazers has a different set of criteria for E&M services as related to medical decision-making than most other carriers do. All of this will require a certain amount of evaluation, study, and revamping of your billing as you move into the next generation of Medicare billing.
Finally, we would like to re-emphasize the combined databases and the improved databases that will be required for the multi-state programs and the impact it will have on you in the demand for quality, cost-efficient care as we move forward with another phase of payment reform for the Medicare program.
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
