Certified Inpatient Coding (CIC) Practice Exam

What corrective actions can a MAC impose as a result of a complex medical review?

1. Provider notification / feedback only

2. Prepayment or Postpayment review only

3. Both provider notification and prepayment/postpayment review

4. Criminal litigation only

The correct answer is: Both provider notification and prepayment/postpayment review

The selection of both provider notification and prepayment/postpayment review as a corrective action that a Medicare Administrative Contractor (MAC) can impose following a complex medical review is accurate because it reflects the comprehensive approach during the compliance process. In cases where a complex medical review reveals issues, MACs engage in notifying providers to communicate findings, which allows them the opportunity to address specific concerns regarding their billing or coding practices. This notification serves as critical feedback and is part of a proactive approach to ensure that providers understand the rationale behind any potential discrepancies in their claims. Additionally, MACs can initiate prepayment or postpayment review processes. This means that they may conduct thorough examinations of claims either before they are paid (prepayment review) or after payment has been made (postpayment review). These practices serve as further mechanisms to safeguard against improper payments and to ensure compliance with Medicare guidelines. Overall, the ability to implement both types of corrective actions—provider notifications for feedback and rigorous claims review processes—ensures that MACs can effectively enforce adherence to regulations and enhance the integrity of the Medicare program.