The health care regulatory environment has undergone unparalleled changes leading to significant angst for medical practitioners of all specialties. The financial challenges associated with the Affordable Care Act are daunting as the government is ratcheting up its enforcement efforts against health care providers. The government is taking a “return on investment” approach to health care fraud and abuse using data mining tools to identify potential targets. Unfortunately, non-government commercial payers are also using similar tactics to aggressively recoup overpayments and intimidate providers into reducing utilization.

MCA provides integrated health care solutions to clients to level the playing field. MCA’s specialized approach demonstrates our awareness and commitment to provide education in medical record documentation, billing and coding. MCA’s clients have experienced unequaled success in reducing audit exposure while promoting an organizational commitment to compliance.

Medical practices of all types are being subjected 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’s 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 audits on either a pre- or post-payment basis to identify weaknesses and decrease the risk of external audit vulnerability. Since 1999, MCA has defended more than 2,000 overpayment cases for medical practices of all specialties.
Education is the single most important element to achieving billing and coding compliance! The extensive 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: one-on-one teaching, group education, or clinician training. MCA will tailor a program that specifically meets the needs of the individual client, multi-specialty clinics, facilities, or medical specialty societies. Education should be viewed as "preventive medicine for the health care practitioner." MCA education programs include: Medical Record Documentation, Audit Prevention Principles, ICD-10-CM Coding, CPT and HCPCS Coding, and Understanding Medicare Part B Guidelines.
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 physician practices. An effective compliance program is crucial in a practice’s navigation of the dynamics of health care regulation and enforcement. MCA offers a team of experienced professionals to assist health care law firms by performing baseline assessments to identify compliance vulnerabilities in billing, CPT and ICD-10-CM coding, and medical record documentation. Recognition of these weak points is conducive to the development of effective billing and coding education programs, development of policy and procedure manuals, and implementation of the finished compliance program.
The number of litigation and dispute resolution actions continues to grow due to ever-changing and complex regulatory requirements and related government oversight and scrutiny. The MCA team is comprised of physicians, nurses, statisticians, compliance officers, and coding and billing experts. Whether your litigation needs are in the form of coding assessments, compliance analysis, dispute resolution, independent review, or a corrective action plan, the professionals at MCA are ready to assist.
MCA offers a team of experienced health care professionals who have been 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 professionals 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 advise legal counsel on behalf of 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, have 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, often in 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 expanded focus has been placed on protecting the Medicare Trust Fund, health care providers find themselves struggling to respond to an increased number of record requests and payer audits. Without preparation and proper response, these record requests and subsequent payer reviews often lead to substantial overpayment assessments. Medical practices have to navigate through the appeals process, which is both labor intensive and costly. Over the last two decades, MCA has defended over 2,000 medical practices of various specialties with unparalleled success.
Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), Zone Program Integrity Contractors (ZPICs), commercial insurance companies, 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 often 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 evaluated and the modifiers verified 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 applicable, Medicare Advantage Plan and commercial insurance company websites are accessed to locate any applicable medical review policies that need to also be considered.

MCA’s unparalleled success in defending health care providers and suppliers of all specialties in retrospective payment audits and prepayment reviews 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) or Integrity Agreements (IA). Medical practitioners and health care entities entering into a CIA or IA with the Office of the Inspector General are required to engage an IRO to perform a review of a scientific random sample of claims that were reimbursed by federal payers. MCA professionals are uniquely qualified to function as an IRO for Corporate Integrity Agreements or Integrity Agreements. MCA also has experience as an IRO for Focus Arrangement Integrity Agreements. The IRO is required to perform an annual Arrangements Review, which consists of a Systems Review and a Transactions Review. The focus of these Arrangements Reviews is to make certain the entities are adhering to the provisions of the Anti-Kickback Statute and Stark Law.
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. The Centers for Medicare & Medicaid Services Self-Referral Disclosure Protocol establishes a six-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 Administrative 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’s professional staff includes 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.