Medicare providers have a lot of challenges to contend with—and meeting those challenges can be tough. But, you don’t always have to go it alone, because while you can’t always count on CMS to provide clear guidance on how to comply with all the regulations that apply to you, you do have other resources at your disposal when you need answers—quick. Let’s talk about one such resource: your Medicare Administrative Contractor (MAC).

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Your Medicare Go-To

Even if you think you’re doing everything right, you could unknowingly be throwing up red flags to Medicare. To avoid raising suspicions about questionable billing practices—which could give way to a tedious claims appeal process—you have to stay ahead of those flubs. Luckily, you’ve got someone to help you whip your billing processes into shape: each Medicare provider has access to a MAC who serves his or her specific geographic region. Essentially, your MAC acts as your single point of contact for all Medicare fee-for-service claims-related matters—whether you bill under Medicare Part A or Part B. That includes providing training and guidance on the claims submission process.

By educating providers on the ins and outs of ever-changing Medicare policies—and ensuring they know how to submit paperwork correctly—MACs make it easier for providers to create a snag-free claims process. And that means healthcare practitioners can worry less about potential rejections and denials—and focus more on providing amazing patient care.

The Appeal Starter

Now, in cases when a claim is denied—or not handled the way you think it should have been—you can appeal Medicare’s decision. There are up to five levels in the Medicare appeals process, and MACs kick it all off by providing a review at the first level, known as redetermination. Not many providers go to the trouble of contesting denied claims, but more than half of all appealed claims bring about positive results. Who wouldn’t want to receive all the reimbursement they deserve?

The Ugly World of Audits

While MACs are obviously meant to serve as a help resource for Medicare providers, they also can play the role of rule enforcer—especially when it comes to audits. As explained here, there are three major audit triggers for rehab therapists:

  • Excessive use of the KX modifier
  • Multiple therapists billing under a single provider number (rather than billing separately)
  • Billing an excessive number of codes per date of service

If your practice falls into these billing traps—or employs any of the questionable billing practices covered in this article—you may be subject to an audit. MACs are often involved in the audit process, especially during probe audits. With these audits, your MAC can open your books to perform a prepayment review of your claims targeting “either particular services or particular specialties.” Essentially, if you meet certain criteria, auditors will pull a sample of your already-submitted claims to check for accuracy prior to payment. From there, you will be requested to provide additional documentation by a certain deadline before you can receive proper reimbursement for the claims. If an audit goes poorly, and your MAC suspects negligence or fraud, the MAC can refer your case to the appropriate agency for further investigation.


Taking a proactive approach to getting your billing practices in order can help better ensure you’re complying with Medicare’s rules and regulations—and, thus, keep you from having to deal with any potential legal complications. Remember, your MAC is your primary point of contact for ensuring accuracy in the receipt, processing, and payment of your Medicare claims. So, don’t be shy about contacting the MAC serving your region with any questions regarding these processes. (Not sure who that is? Visit this CMS page to view a Medicare Administrative Contractor list.)

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