Who audits claim data on an ongoing basis to check for inappropriate billing under the Medical Review Program?

The Medicare Administrative Contractor (MAC) plays a crucial role in the audit process related to claims data under the Medical Review Program. MACs are private organizations contracted by the Centers for Medicare & Medicaid Services (CMS) to manage claims processing and ensure that services provided to Medicare beneficiaries are billed correctly.

One of their responsibilities is to conduct ongoing audits of claims data to identify and review any inappropriate billing practices. This oversight helps to protect the Medicare system from fraud and abuse, ensuring that only legitimate claims are paid. By scrutinizing billing patterns and conducting targeted audits, MACs contribute to maintaining the integrity of the Medicare program.

In contrast, while other organizations, such as the Office of Inspector General (OIG) and the Medicaid Audit Commission (MAC), do engage in oversight and audits of healthcare spending, they serve different functions or focus on different populations than MACs under the Medicare umbrella. National Government Services (NGS) is a specific type of MAC; however, the broader role of the MAC encompasses various contractors in the Medicare system responsible for auditing claims data.