To assure the integrity of Medicare Trust Fund dollars through program integrity and compliance efforts by actively seeking out suspected Medicare program vulnerabilities through a variety of methods, assessing scope and severity of risks, and working collaboratively within and outside CMS to develop, help implement, and monitor corrective actions.
The collection of information and clinical review of medical records by Medicare Administrative Contractors to ensure that payment is made only for services that meet the Medicare coverage, coding and medical necessity requirements.
A contractor that performs Medicare fee-for-service Part B claims administration services for physicians, non-physician practitioners, and suppliers, where the contract was implemented under statutory authority in effect prior to the enactment of Section 1874A of the Social Security Act.
“By July 2013 all carriers and FIs will have transferred their claims administration responsibilities to the MAC in the relevant state.”
Comprehensive Error Rate Testing (CERT) program is to measure improper payments in the Medicare fee-for-service (FFS) program. The CERT program cannot be considered a measure of fraud. Since the CERT program uses random samples to select claims, reviewers are often unable to see provider billing patterns that indicate potential fraud when making payment determinations. CERT is designed to comply with the Improper Payments Elimination and Recovery Act of 2010.
Durable Medical Equipment - Medicare Administrative Contractor is a specialty MAC whose contract is awarded through competitive procedures and which provides for the processing of Medicare claims for durable medical equipment, prosthetics, orthotics, and supplies in keeping with 42 CFR 421.210.
Fiscal Intermediary is a contractor that performs Medicare fee-for-service Part A claims administration services for institutional providers (such as hospitals, skilled nursing facilities, etc.) where the contract was implemented under statutory authority in effect prior to the enactment of Section 1874A of the Social Security Act.
“By July 2013 all FIs and Carriers will have transferred their claims administration responsibilities to the MAC in the relevant state.”
Medicare Administrative Contractor is a contractor that performs Medicare fee-for-service claims administration services that is awarded a contract through competitive procedures in keeping with Section 1874A of the Social Security Act.
The Payment Error Rate Measurement (PERM) program measures improper payments in Medicaid and CHIP and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review. It is important to note the error rate is not a "fraud rate" but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements.
Zone Program Integrity Contractors. In each jurisdiction one (ZPIC) will be responsible for program integrity oversight and functions for all Medicare-related claims. Because ZPICs will investigate cases of Medicare fraud involving all healthcare providers in a geographic region, they will have the ability to detect cross-billing and relationships among healthcare providers, which will lead to increased scrutiny of providers working across health care settings. ZPICs will also compare data from Medicare and Medicaid claims to identify fraudulent activities between the programs, a process known as Medi-Medi data matching.