What’s a MAC and what do they do?

A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.  CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program.  MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.  MACs perform many activities including:

• Process Medicare FFS claims
• Make and account for Medicare FFS payments
• Enroll providers in the Medicare FFS program
• Handle provider reimbursement services and audit institutional provider cost reports
• Handle redetermination requests (1st stage appeals process)
• Respond to provider inquiries
• Educate providers about Medicare FFS billing requirements
• Establish local coverage determinations (LCD’s)
• Review medical records for selected claims
• Coordinate with CMS and other FFS contractors

https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs

Overview:

MACs (Medicare Administrative Contractors) administer Medicare benefits for the states. The MACs establish policies for benefit coverage. These policies are called LCDs (Local Coverage Determinations).

In the past, Medicare coverage of Botulinum Toxin Treatment for CD and other FDA approved uses was straightforward across all MACs and requirements were minimal. An example is prior authorization requirements with Medicare. Unlike traditional commercial medical policies, a prior authorization was not required for Medicare patients in the past. 

Some of the MACs (but not all) are considering new requirements that might impact CD and other Botulinum Toxin patients.

Some of the ideas under consideration include:

•             Require prior authorization for all patients (a prior authorization is usually good for a 1 year period, then must be renewed)

•             Require a baseline TWSTRS score to establish medical necessity

•             Ensure chart notes support medical necessity

•             Require documentation supporting dose and muscles injection

•             Ensure coverage is consistent with exact product label information such as dose and time between treatment

What patients should know:

•             In the future, you HCP might be required to collect additional information to support coverage of your Botulinum Toxin injections