With regulatory requirements, ICD-10, government oversight and scrutiny overshadowing the current health care environment, maintaining a successful clinical practice With more than XX years of experience, MCA provides integrated healthcare solutions to clients with a variety of needs. Understanding that each of our service lines requires a unique focus, MCA’s specialized approach demonstrates our awareness and commitment to provide support in the areas of regulation, correct coding, healthcare education, and litigation support.

Medical practices of all types find themselves responding to an increasing number of audits. Federal, State and commercial payer audits are conducted to determine the medical necessity of services provided and accuracy of the related claim submission. MCA professionals are well trained in medical record documentation and audit principles. Our auditing experts do more than uncover opportunities, errors, risks and areas of improvement. Utilizing the audit results, MCA will develop custom education and training to meet your practice needs. Our auditors work directly with your staff to achieve and maintain a higher level of effectiveness. Many health care practitioners rely on MCA to perform proactive audits on either a pre or post payment basis to identify weaknesses and decrease the risk of external audit vulnerability. MCA offers the following services to our clients: Coding Compliance Audits Coder Education and Training Pre-RAC Risk Assessment Reviews Appeal writing and denial.
Education, possibly the single most important element to compliance! The vast experience of the professionals at MCA, allows for creation of a comprehensive and customized compliance education program .Our education programs are customized to meet the needs of your practice: for one-on-one teaching, group education, or clinician training. MCA will tailor a program which specifically meets the needs of the individual client, multi-specialty clinics, facilities, medical specialty societies. The team includes an AAPC PMCC instructor and an AHIMA approved ICD-10 instructor. Education should be viewed as "preventive medicine for the health care practitioner". MCA Education Programs include: ICD-10-CM Coding CPT and HCPCS Coding Coding for the Podiatry Office Evaluation and Management Services Coding Certification Preparatory Courses Risk Adjustment (if in Karen’s skill set) Understanding Medicare Physician Regulations.
The Office of the Inspector General, U.S. Department of Health and Human Services (DHHS) requires effective compliance programs for facilities and strongly recommends their use in the physician practice. An effective compliance program is significant in a practice’s navigation of the dynamics of healthcare regulation and enforcement. MCA offers a team of experienced professionals to assist in initial review of billing and coding procedures, development of policy and procedure manuals, design of training programs, and implementation of the finished compliance program.
The number of litigation and dispute resolution actions continues to grow due to the ever changing, complex, regulatory requirements, the related government oversight and scrutiny. The MCA team is comprised of physicians, nurses, statisticians, compliance officers, coding and billing experts. Whether your litigation needs is in the form of assessment, compliance assessment, dispute resolution, coding analysis, internal audit, independent review, or a corrective action plan the professionals at MCA are able to assist.
MCA offers a team of experienced health care professionals qualified as expert witnesses in both State and Federal Court to assist with litigation needs. A favorable decision is often dependent on the testimony of experienced professionals. The professional at MCA have demonstrated knowledge and the ability to testify in a persuasive and effective manner.
MCA professionals are often called upon to evaluate disputes and mediate on behalf on the practitioner when appropriate. Our professionals objectively evaluate the matter and render impartial recommendations.
MCA’s extensive experience and knowledge of the health care industry, particularly billing and coding, has proved invaluable to legal professionals in the defense of criminal and administrative actions taken by Federal, State and commercial payers. MCA is viewed as one of the country’s foremost authorities in health care compliance issues and its ability to assist legal professionals in these often complex cases.
In order to protect Federal and State funds, the Medicare and Medicaid programs are required to conduct post payment reviews. As regulatory complexity has increased and an increased focus has been placed on the misappropriation of Medicare payments, healthcare providers find themselves struggling to respond to an increased number of record requests and payer audit. Without preparation and proper response these record requests and subsequent payer review often lead to substantial overpayment assessments. Medical practices find themselves navigating the appeals process which is both labor intensive and costly. Over the last decade, MCA has defended over 750 medical practices of various specialties with unparalleled success.
The starting point of every Corporate Compliance Plan should be an initial assessment or Baseline audit. MCA’s professionals are experienced in review of process, billing and coding protocols, information systems, medical record documentation and adherence to State and Federal regulations and guidelines. MCA consultants are required to stay current in all aspects of health care compliance and day-to-day medical practice operations in order to insure the highest quality services are provided.
Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), Zone Program Integrity Contractors (ZPICs), and Commercial Insurance Company and Medicare Advantage Plan Special Investigative Units (SIUs) routinely identify and scrutinize providers and suppliers suspected of inappropriate or excessive billing of services or supplies. Prepayment reviews are oftentimes disruptive to medical practices and routinely result in cash flow being severely reduced or delayed. Ill-trained or inexperienced auditors frequently render negative decisions that can only be resolved by filing appeals, which are time-consuming and result in the unwarranted stress and waste of your staff’s time.

Prepayment review is not terminated until the provider or supplier has improved the billing accuracy percentage significantly. This can be a daunting task because the auditors rarely provide specific feedback to justify the denial rationale.

MCA’s specialists are comprised of Certified Professional Coders (CPCs) with review experience in all medical specialties, and are members of the American Academy of Professional Coders. MCA’s specialists evaluate each reviewed claim to ensure the documentation establishes medical necessity for all the services and supplies. The CPT codes and ICD 10 CM codes are authenticated and the modifiers evaluated to ascertain their validity. MCA’s specialists also use Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) to influence their decisions for Medicare Part B claims. When available, Medicare Advantage Plan and commercial insurance company websites are accessed to locate any applicable medical review policies that need to be considered as well.

MCA’s unparalleled success in defending healthcare providers and suppliers of all specialties in retrospective payment audits is invaluable in providing the necessary education to convince even the most aggressive insurance auditor that the services were medically necessary and billed appropriately.
The services of an Independent Review Organization (IRO) are integral to most Corporate Integrity Agreements (CIA). Healthcare and other organizations that enter into a CIA with the government are required to retain an IRO, to review a Federal healthcare programs claims submission sample. MCA professional are uniquely qualified to function as an IRO for corporate integrity agreements. Our team has numerous years of experience in healthcare compliance consulting. MCA has provided IRO services for a variety of healthcare providers.
Section 6402(a) of the Affordable Care Act (ACA) requires a person who has received an overpayment to report and return the overpayment within 60 days after the date on which it was identified. CMS’ Self-Referral Disclosure Protocol establishes a 6-year lookback period. This seems straightforward; however, sometimes looks are deceiving.

Providers and suppliers who fail to report and return overpayments face potential False Claims Act (FCA) liability, Civil Monetary Penalties and exclusion from federal health care programs. When there is credible information concerning a potential overpayment, the overpaid provider must undertake reasonable diligence to determine whether an overpayment has been received and the amount. It is essential that trained professionals evaluate the credible evidence to determine its validity and the amount of the overpayment.

A provider or supplier waives all rights to appeal if the overpayment is self-disclosed. The mere fact that a Medicare Administrator Contractor alleges overcharges by a provider or supplier does not necessarily obligate the provider to refund the alleged overpayment and relinquish appeal rights. MCA professionals have extensive experience in evaluating and calculating overpayments, when substantiated. MCA has an experienced doctorate-level statistician who uses the most up-to-date statistically valid audit sampling methodologies. The use of statistical sampling to project overpayments is far less cumbersome and reduces the expense of the audit.