Foundation models provide highly descriptive representations for medical images, yet their reliability degrades under distribution shifts arising from changes in patients, devices, or acquisition conditions. Reliable out-of-distribution (OOD) detection is therefore essential for safe deployment. Recent post-hoc detectors efficiently exploit frozen embeddings (e.g., kNN), whereas reconstruction-based OOD detection in latent feature space has seen limited adoption due to inconsistent performance. In this work, we show that the limitation of reconstruction-based methods in latent space does not stem from poor reconstruction quality, but from how reconstruction errors are scored. Standard L2 residual norms collapse the anisotropic residual structure, thereby suppressing informative deviations. To address this limitation, we introduce MaRS (Mahalanobis Residual Scoring), a label-free OOD detector that learns an in-distribution manifold using a lightweight autoencoder and measures deviation via a Mahalanobis distance on reconstruction residuals, yielding variance-aware OOD scores. Across three imaging modalities, multiple types of distribution shift, and different model families and scales, MaRS outperforms established confidence-, distance-, and reconstruction-based baselines, while remaining fully post-hoc and lightweight. The code is available at https://github.com/francescodisalvo05/mars.

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