Q&A: RACs, MACs, and CERT

June 28, 2018

CDI Strategies - Volume 12, Issue 29

Q: What’s the difference between Recovery Audit Contractors (RAC), Medicare Administrative Contractors (MAC), and the Comprehensive Error Rate Test (CERT)?

A: CMS began several initiatives to prevent or identify improper payments made under the Medicare Fee-For-Service (FFS) program, over the years. Some of them aim to capture inappropriate claims before CMS processes the claim and others to recover improper payments after paying a claim. Their goal is to reduce improper payments and to protect the monies of the Medicare Trust Fund.

MACs are private healthcare insurers which process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare FFS beneficiaries within a geographic jurisdiction. They process claims from physicians, hospitals, and other healthcare professionals and submit payment to those providers according to Medicare rules and regulations. Their responsibilities also include identifying and correcting underpayments and overpayments of these claims.

The goal of the CERT program is to reduce improper payments and subsequently by doing so, lower the CERT error rate through education efforts. The program developed by CMS, randomly audits claims monthly to determine if they were processed correctly. The information is then used to determine the cause of errors and work to resolve them. The information from the CERT programs is a good indicator of how claims errors in the Medicare FFS Program affect the Medicare Trust Fund, which, of course, CMS needs to protect.

Finally, the RAC program was created to identify improper Medicare payments. RAC auditors are private contractors paid on commission by the government. They review claims on a post-payment basis to identify and correct potential overpayments and underpayments to claims specific to Medicare Part A and Part B (hospital and physician practices). RACs are required to maintain an accuracy rate of at least 95%. Proposed review topics can be found on the cms.gov website.

CDI professionals need to understand where to find information about these programs and their reports in order to adjust review efforts and meet any documentation needs which arise from them. For additional information, check out these resources:

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.

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