One of the primary stated goals of the Centers for Medicare & Medicaid Services (CMS) is to pay correct amounts to legitimate providers, for covered, correctly coded and correctly billed services, provided to an eligible beneficiary. To achieve its goal of lowering error rates, CMS utilizes the services of Affiliated Contractors (ACs), Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and Comprehensive Error Rate Testing (CERT) contractors. These contractors assist in the process of preventing and recovering erroneous payments. In addition to reducing erroneous payments, CMS has a goal of protecting the program from potential fraud. In pursuit of this goal, CMS contracts with Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs). PSCs and ZPICs refer cases of potential fraud to the Department of Health and Human Services (HHS), Office of Inspector General (OIG), Office of Investigations (OI) and may also furnish requested information on ongoing fraud investigations to State Attorneys General and to State agencies.
Together, these contractors and units have the full range of remedies and actions available to deal with questionable, improper or abusive practices of practitioners, providers and suppliers under publicly funded health care programs.
If you believe you're the subject of program integrity contractor review and need legal representation, or if you need assistance maintaining and enhancing your regulatory compliance program, contact John Little, Attorney at Law, PC.
ACs, MACs, CERTs and RACs (Errors)One of the primary stated goals of the Centers for Medicare & Medicaid Services (CMS) is to pay correct amounts to legitimate providers, for covered, correctly coded and correctly billed services, provided to an eligible beneficiary. To achieve its goal of lowering error rates, CMS follows three parallel strategies:
CMS implemented the Comprehensive Error Rate Testing (CERT) program pursuant to the Improper Payment Information Act in order to establish error rates and estimates of improper payments.
In the Tax Relief and Health Care Act of 2006, Congress required a permanent and national Recovery Audit Contractor (RAC) program to be in place by January 1, 2010. The stated goal of the Recovery Audit Program is to identify improper payments (which may be overpayments or underpayments) made on claims of health care services provided to Medicare beneficiaries. The national RAC program is the outgrowth of a demonstration program covering health care providers and suppliers in California, Florida, New York, Massachusetts, South Carolina and Arizona which resulted in $900 million in overpayments being returned to Medicare and $38 million in underpayments returned to health care providers. RACs are paid on a contingency fee basis on both the overpayments and underpayments they find.
Health care providers subject to RAC review include hospitals, physician practices, nursing homes, home health agencies, durable medical equipment (DME) suppliers and any other provider or supplier that bills Medicare Parts A and B. Providers subject to RAC review should:
Affiliated Contractors (ACs) are Carriers and Fiscal Intermediaries, and as required by Section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), CMS is in the process of awarding Medicare claims processing contracts through competitive procedures resulting in replacing ACs with new contract entities called Medicare Administrative Contractors (MACs). ACs and MACs primarily use error rates produced by the CERT program and vulnerabilities identified through the Recovery Audit Contractor (RAC) program to identify where to target their improper payment prevention efforts. ACs and MACs analyze their internal data to determine which corrective actions would be best to prevent CERT and RAC identified vulnerabilities in the future.
CMS has determined that most improper payments in the Medicare Fee for Service (FFS) program occur because a provider did not comply with Medicare’s coverage, coding or billing rules. Therefore, the cornerstone of AC and MAC efforts to prevent improper payments is each contractors’ Error Rate Reduction Plan (ERRP), which includes initiatives to help providers comply with the rules. These initiatives usually fall into one of three categories:
If you believe you're the subject of program integrity contractor review and need legal representation, or if you need assistance maintaining and enhancing your regulatory compliance program, contact John Little, Attorney at Law, PC.
PSCs and ZPICs (Fraud)In addition to reducing erroneous payments, CMS has a goal of protecting the program from potential fraud. In pursuit of this goal, CMS contracts with Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs). The primary task of PSCs and ZPICs is to identify cases of suspected fraud, develop them thoroughly and in a timely manner, and take immediate action to ensure the integrity of Medicare Trust Fund payments. PSCs and ZPICs are charged with:
PSCs and ZPICs refer cases of potential fraud to the Department of Health and Human Services (HHS), Office of Inspector General (OIG), Office of Investigations (OI) and may also furnish requested information on ongoing fraud investigations to State Attorneys General and to State agencies.
If you believe you're the subject of program integrity contractor review and need legal representation, or if you need assistance maintaining and enhancing your regulatory compliance program, contact John Little, Attorney at Law, PC.
Referral to OIGPSCs and ZPICs are required to immediately advise the OIG/OI and maintain internal documentation on these communications when it receives allegations with one or more of the following characteristics, regardless of dollar thresholds or subject matter:
The OIG/OI will typically exercise one or more of the following options when deciding whether to accept a case:
If you believe you're the subject of program integrity contractor review and need legal representation, or if you need assistance maintaining and enhancing your regulatory compliance program, contact John Little, Attorney at Law, PC.
Corrective Actions and SanctionsSanctions which may be imposed on providers include the full range of administrative remedies and actions available to HHS and law enforcement to deal with questionable, improper or abusive practices of practitioners, providers and suppliers under publicly funded health care programs. Of course, he most serious of these sanctions, exclusions, Civil Monetary Penalties (CMPs) and criminal prosecutions. However, other, less severe administrative remedies may precede more punitive sanctions affecting participation in the programs. The corrective actions that PSCs, ZPICs, ACs, and MACs are required to initially consider are:
If you believe you're the subject of program integrity contractor review and need legal representation, or if you need assistance maintaining and enhancing your regulatory compliance program, contact John Little, Attorney at Law, PC. |
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