Mock MAC Audit Scenarios
Practice responding to real MAC audit requests with detailed examples and best practices
Understanding MAC Audits
Medicare Administrative Contractors (MACs) conduct audits to verify that IRF claims are accurate, medically necessary, and supported by documentation. When Oasis Point receives an audit request, the IRF-PAI Coordinator must respond within 45 days with complete medical records and supporting documentation.
Common Audit Types:
- • Prepayment Review: MAC reviews claims BEFORE payment is issued
- • Post-payment Review: MAC reviews claims AFTER payment (may require refund if denied)
- • Targeted Probe & Educate: MAC identifies facilities with high error rates for education
- • Comprehensive Error Rate Testing (CERT): Random sample to measure national error rates
Mock Audit Scenarios with Response Examples
MAC Audit Response Best Practices
Before the Audit
- ✓ Conduct monthly internal audits of IRF-PAI accuracy
- ✓ Maintain organized medical records with clear documentation
- ✓ Ensure FIM scores match all clinical documentation
- ✓ Code only active, treated comorbidities
- ✓ Verify diagnosis matches acute hospital records
- ✓ Track 60% Rule compliance daily
During the Audit
- ✓ Respond within 45-day deadline
- ✓ Conduct internal pre-audit review first
- ✓ Create evidence matrices for FIM scores and comorbidities
- ✓ Write detailed cover letter addressing MAC concerns
- ✓ Organize records with tabs and highlighting
- ✓ Proactively disclose and correct any errors found
- ✓ Submit corrective action plan if issues identified
Key Success Factors:
- • Transparency: Acknowledge errors and demonstrate corrective actions
- • Organization: Submit well-organized, highlighted documentation
- • Evidence: Provide objective evidence (labs, imaging, orders) not just narrative notes
- • Consistency: Ensure all documentation tells the same story
- • Timeliness: Never miss the 45-day deadline