In recent years, the government and states have intensified their efforts to root out fraud, waste, and abuse in the Medicare and Medicaid programs. Agencies like the Department of Justice (DOJ), the Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS) have joined forces in an effort to streamline and combat fraud in new and, most likely, more effective ways.
The following desscriptions are intended to illustrate the magnitude and complexity of these efforts within the Medicare and Medicaid programs.
Medicare
Medicare Integrity Program (MIP)
The term “program integrity” refers to all of the agencies’ programs aimed at detecting and preventing fraud in the Medicare Fee-For-Service, Medicare Advantage, and Part D programs; ensuring the integrity of the Medicare Fee-For-Service enrollment process; and promoting compliance with Medicare rules.
Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs): These entities are responsible for preventing, detecting, and deterring Medicare fraud. They do so by identifying program vulnerabilities—areas that are at high risk for fraud; investigating allegations of fraud made by beneficiaries, providers, CMS, OIG, and other sources; exploring all available sources of fraud leads in its jurisdiction, including the Medicare Fraud Control Unit (MFCU) and its corporate anti-fraud unit; and initiating appropriate administrative actions to deny or suspend payments that should not be made to providers.
PSCs and ZPICs are required to use a variety of techniques and tools, both proactive and reactive, to address any potentially fraudulent billing practices, data analysis, the Internet, the Fraud Investigation Database, the news media, and the identification of leads by any internal, Affiliated Contractor (AC) or Medicare Administrative Contractor (MAC) component.
Medicare Contractors And Programs
Technically speaking, PSCs and ZPICs are the MIP contractors. However, MACs can qualify as ZPICs. More importantly, there is cooperation among the various claims review contractors and MIP contractors. PSCs, ZPICs, ACs, and MACs must ensure that they pay the right amount for covered and correctly coded services rendered to eligible beneficiaries by legitimate providers.
CMS strategies in meeting this goal include preventing fraud through effective enrollment and through education of providers and beneficiaries; early detection through medical review and data analysis; and close coordination with PSCs, ZPICs, ACs, MACs, and law enforcement agencies.
Fiscal Intermediaries (FIs) and Medicare Administrative Contractors (MACs): With the goal of preventing improper payments, FIs and MACs identify suspected billing problems through analysis of claims data and other information, such as complaints. If the MAC verifies that an error exists through a review of a small sample of claims, the contractor classifies the severity of the problem as minor, moderate, or significant and imposes corrective actions.
Comprehensive Error Rate Testing (CERT): The main objective of CERT is to measure the degree to which CMS and its contractors are meeting the goal of “paying it right.” CMS established two programs to monitor the accuracy of the Medicare Fee-For-Service (FFS) program: the CERT program and the Hospital Payment Monitoring Program (HPMP). HPMP monitors prospective payment system short-term and long-term acute care inpatient hospitalizations and discharges. The CERT program monitors all other claims.
Recovery Audit Contractors (RACs): The goal of the RAC program is to detect and correct past improper payments so that CMS, carriers, FIs, and MACs can implement actions that will prevent future improper payments. The RAC program is tasked with applying statutes and regulations; CMS national coverage, payment, and billing policies; and local coverage decisions that have been approved by the Medicare claims processing contractors.
Medicaid
Medicaid Integrity Program (MIP)
Created under the Deficit Reduction Act of 2005, MIP is the first comprehensive federal strategy to prevent and reduce fraud, waste, and abuse in the Medicaid program. CMS has two broad responsibilities, including:
- Hiring Medicaid Integrity Contractors (MICs) to review Medicaid provider activities, audit claims, identify overpayments, and educate providers and others in Medicaid integrity issues.
- Providing effective support and assistance to the states in their efforts to combat Medicaid provider fraud and abuse. The states remain primarily responsible for combating Medicaid fraud.
The Medicaid Integrity Group (MIG) is part of the CMS Center for Medicaid and State Operations, which serves as the focal point for all CMS activities relating to Medicaid, the Children’s Health Insurance Program (CHIP), the Clinical Laboratory Improvement Act, and survey and certification of health facilities.
MIG detects and prevents fraud, waste, and abuse in Medicaid; supports and assists the states; identifies overpayments and reduces the inappropriate payment of Medicaid claims; educates on payment integrity and quality of care; makes referrals of suspected practices and providers to federal and/or state law enforcement agencies; and conducts data mining and analysis to identify emerging trends.
Medicaid Contractors And Programs
There are three different types of MICs:
- Review-of-Provider MICs analyze claims to identify potential vulnerabilities, provide leads and target audits for Audit MICS, focus on aberrant billing practices, and work with CMS’ Division of Fraud Research & Detection.
- Audit MICs conduct post-payment audits, perform field audits and desk reviews, and identify overpayments. These MICs also make referrals to the Department of Health and Human Services (HHS) and OIG, which, in turn, share the information with state Medicaid Fraud Control Units. No Audit MIC is ever random, and MIC auditors will not duplicate state investigations.
- Education MICs develop training materials and awareness campaigns and highlight value in preventing fraud and abuse. No contracts have been awarded yet.
Payment Error Rate Measurement (PERM): PERM measures improper payments in the Medicaid program, including CHIP, and performs statistical calculations, medical records collection, and medical and data processing reviews of selected claims.
Medicaid Fraud Control Unit (MFCU): A single identifiable entity of state government, annually certified by HHS. MFCUs conduct a statewide program for the investigation and prosecution of health care providers that defraud the Medicaid program. MFCUs also review complaints of abuse or neglect of nursing facility residents and are charged with investigating fraud in the administration of the program.
Medicaid Management Information System (MMIS): The master claims database that identifies potential Medicaid claims problems.
The regional office receives a subset of the MMIS database and uses that subset to identify algorithms. Once an issue is identified, staff pull the provider number from the subset, and the CMS regional office sends a letter to the respective state’s OIG to ascertain whether any of the providers are already under audit or investigation.
CMS has identified problems with the database, such as stale data and a lack of contact names or numbers.
Joint Medicare And Medicaid Initiatives
Provider Compliance Group: The Provider Compliance Group has responsibilities for both Medicare and Medicaid. The group must implement and maintain medical review activities, administer the CERT and PERM programs, conduct data analysis and assess the scope and severity of suspected vulnerabilities, and administer the RAC program.
Joint Agency Programs: The Health Care Fraud Prevention and Enforcement (HEAT) program was announced in May 2009 and is a joint task force consisting of “senior level” leadership from both DOJ and HHS. HEAT builds on the Medicare Fraud Strike Force program initiated in south Florida and utilizes advanced data analysis techniques to identify and detect fraud schemes. HEAT plans to enlist providers to help ensure integrity of billing practices and will focus on both Medicare and Medicaid providers who are believed to be defrauding the government.
Medi-Medi: Established in 2006, Medi-Medi is designed to identify improper billing and utilization patterns by matching Medicare and Medicaid claims information on providers and beneficiaries to reduce fraudulent schemes that cross program boundaries. CMS contracts with third parties to identify program vulnerabilities through the examination of billing and payment abnormalities.
Source: Dianne De La Mare, vice president of regulatory affairs, American Health Care Association (AHCA), Priscilla Shoemaker, legal counsel, AHCA; the Centers for Medicare & Medicaid Services; and the U.S. Department of Health and Human Services Office of the Inspector General