The Medicare Integrity Program (MIP) provides funds to the Centers for Medicare & Services (CMS
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services, previously known as the Health Care Financing Administration, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state government…
What is program integrity in Medicaid?
Sep 06, 2006 · The Medicare Integrity Program (MIP) provides funds to the Centers for Medicare & Medicaid Services (CMS--the agency that administers Medicare--to safeguard over $300 billion in program payments made on behalf of its beneficiaries.
What is the Medicare Integrity Program (MIP)?
The Medicare Integrity Program is the Centers for Medicare & Medicaid Services primary program for safeguarding the Medicare Trust Funds against fraud, waste and abuse. The program conducts reviews and investigations of Medicare expenditures to ensure Trust Fund resources are properly utilized for the program's mission.
What is the comprehensive Medicaid integrity plan for 2019-2023?
MAC, CERT and Recovery Auditor staff shall not expend Medicare Integrity Program (MIP)/ MR resources analyzing provider compliance with Medicare rules that do not affect Medicare payment. Examples of such rules include violations of conditions of participation (COPs), or coverage or coding errors that do not change the Medicare payment amount.
How does CMS assess state program integrity efforts?
Please note that CMS and the Program Integrity Contractors are assisted best in these investigations and decisions if Medicare providers/suppliers supply the most comprehensive evidence up-front in order to make the investigative and review process as efficient, effective, and informed as possible. The Program Integrity Contractor will conduct an
What is program integrity in healthcare?
Program integrity activities are meant to ensure that federal and state taxpayer dollars are spent appropriately on delivering quality, necessary care and preventing fraud, waste, and abuse from taking place.
What is the Medicare Program Integrity Manual?
the Manual addresses the detection and prevention of fraud, waste and abuse, as well as the prevention of improper payments in the Medicare fee-for-service (FFS) program.Jun 19, 2020
What is the program integrity?
Program integrity refers to the proper management and function of the Medicaid program to ensure it is providing quality and efficient care while using funds–taxpayer dollars–appropriately, with minimal waste.Dec 10, 2019
What does a Zone Program Integrity Contractor do?
The Zone Program Integrity Contractor (ZPIC) is an entity established in the United States by the Centers for Medicare & Medicaid Services (CMS) to combat fraud, waste and abuse in the Medicare program.
What happens when you get audited by Medicare?
Medicare audits are one of several things that can trigger a larger civil or criminal investigation by federal law enforcement. Usually, auditors con- clude that Medicare has made significant “over- payments”and demand that the audited physician return the money.
What is the number one reason Medicare claims are rejected?
Claim rejections (which don't usually involve denial of payment) are often due to simple clerical errors, such as a patient's name being misspelled, or digits in an ID number being transposed.Feb 5, 2020
What are the responsibilities of the national benefit integrity Medicare Drug integrity Contractor?
National Benefit Integrity (NBI)-Medicare Prescription Drug Integrity Contractor (MEDIC), General Support System(GSS) is used to perform fraud and abuse investigation, support benefit integrity efforts, provide medical review support, national and regional data analysis, and law enforcement support.Mar 29, 2017
What is payment integrity?
Payment integrity is the process by which health plans and payers ensure healthcare claims are paid accurately, both in a pre-pay and post-pay context. It encompasses determining the correct party, membership eligibility, contractual adherence, and fraud, waste and abuse detection and prevention.
What is not a responsibility of a Zone Program integrity Contractor?
ZPICs do not handle complaints, audit cost reports, or process claims. All medical and documentation review is specifically for the purpose of verifying benefit integrity.Jul 19, 2017
What contractors are part of the national group of Program Integrity Contractors?
National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC)...Applied to the following CMS Contractors:Medicare Administrative Contractors (MACs),Supplemental Medical Review Contractor (SMRC),Recovery Audit Contractors (RACs), and the.Comprehensive Error Rate Testing (CERT) Contractor.Jul 7, 2020
Which of the following is a responsibility of Medicaid Integrity Contractors?
CMS has broad responsibilities under the Medicaid Integrity Program to: Hire contractors to review Medicaid provider activities, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issues.
What is a Medicare Zpic audit?
Zone Program Integrity Contractors (ZPIC) are responsible for investigating suspected fraud, waste, or abuse in the Medicare program and healthcare providers. They are given powers to conduct detailed audits on a massive scale on behalf of the Centers for Medicare and Medicaid Services (CMS).
What is Medicare Integrity Program?
The Medicare Integrity Program is the Centers for Medicare & Medicaid Services primary program for safeguarding the Medicare Trust Funds against fraud, waste and abuse. The program conducts reviews and investigations of Medicare expenditures to ensure Trust Fund resources are properly utilized for the program's mission.
What is Medicare Modernization Act?
The Medicare Modernization Act significantly expanded CMS's responsibilities and will require an additional program integrity activity.
What is a prepayment review?
Prepayment review always results in an “initial determination”. Postpayment review occurs when a reviewer makes a claim determination after the claim has been paid. Postpayment review results in either no change to the initial determination or a “revised determination” indicating that an overpayment or underpayment has occurred.
When requesting documentation for post payment review, the MACs, CERT, SMRC, UPICs
When requesting documentation for post-payment review, the MACs, CERT, SMRC, UPICs and RACs shall notify providers when they expect documentation to be received. MACs, CERT, SMRC, UPICs and RACs have the discretion to grant extensions to providers who need more time to comply with the request.
Why is it important to note that the projected overpayment recovered from a provider as a result of a post
Because of the cost report relationship to the overpayment , it is important to note that the projected overpayment recovered from a provider as a result of a postpayment review using statistical sampling for overpayment estimation is based on the interim payment rate in effect at the time of the review.
How long does it take for a MAC to review a prepayment?
The 30 calendar day timeframe applies to prepayment non-medical record reviews and prepayment medical record reviews. The 30 calendar day timeframe does not apply to prepayment reviews of Third Party Liability claims. The MACs shall make and enter a review determination for Third Party Liability claims within 60 calendar days.
Who maintains credentials for medical records?
The MACs, MRAC, CERT, RACs, and UPICs shall maintain a credentials file for each reviewer (including consultants, contract staff, subcontractors, and temporary staff) who performs medical record reviews. The credentials file shall contain at least a copy of the reviewer’s active professional license.
What is MAC data analysis?
When MAC data analysis indicates that a provider-specific potential error exists that cannot be confirmed without requesting and reviewing documentation associated with the claim , the MAC shall review a sample of representative claims. Before deploying significant medical review resources to examine claims identified as potential problems through data analysis, MACs shall take the interim step of selecting a small "probe" sample of generally 20-40 potential problem claims (prepayment or postpayment) to validate the hypothesis that such claims are being billed in error. This ensures that medical review activities are targeted at identified problem areas. The MACs shall ensure that such a sample is large enough to provide confidence in the result, but small enough to limit administrative burden. The CMS encourages the MACs to conduct error validation reviews on a prepayment basis in order to help prevent improper payments.
How long does a MAC have to respond to a rebuttal?
Within 15 calendar days of receipt of a financial rebuttal, MAC staff shall consider the statement and any evidence submitted to reach a determination regarding whether the facts justify the recoupment. However, the MAC shall not delay recovery of any overpayment beyond the date indicated in the review results letter in order to review and respond to the rebuttal statement even if the principal of the debt is modified after reviewing the rebuttal statement (See 42 CFR 405.375(a)). The MAC shall provide a copy of the rebuttal request and a copy of the MAC’s response on the rebuttal outcome to the UPICs.
What is Medicaid Integrity Program?
To fulfill this statutory requirement, the Medicaid Integrity Program (MIP) has procured Audit Medicaid Integrity Contractors (Audit MICs) to conduct provider audits throughout the country.
What is the mission of MII?
The mission of the MII is to provide effective training, tailored to meet the ongoing needs of state Medicaid program integrity employees, with the goal of raising national program integrity performance standards and professionalism.
What are the responsibilities of CMS?
CMS has broad responsibilities under the Medicaid Integrity Program to: 1 Hire contractors to review Medicaid provider activities, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issues 2 Provide effective support and assistance to states in their efforts to combat Medicaid provider fraud and abuse 3 Eliminate and recover improper payments in accordance with the Improper Payments Information Act of 2002, Executive Order 13520 and the Improper Payments Elimination and Recovery Act of 2010
What is CMS triennial review?
Through these triennial reviews, CMS assesses the effectiveness of the state's program integrity efforts, including its compliance with federal statutory and regulatory requirements. The reviews also assist in identifying effective state program integrity activities which may be considered particularly noteworthy and shared with other states.
What is a comprehensive state PI review report?
Comprehensive state PI review reports (and respective follow-up review reports) provide CMS' assessment of the effectiveness of the state's PI efforts, including its compliance with federal statutory and regulatory requirements. They also assist in identifying effective state PI activities which may be noteworthy and shared with other states. Focused PI review reports provide information on reviews conducted to examine specific areas of PI concern in one or more states.
What is a critical provision in the ACA?
A critical provision within the Patient Protection and Affordable Care Act (ACA), enacted on March 23, 2010), as amended by the Health Care and Education Reconciliation Act of 2010, enacted on March 30, 2010) is Section 6401 (a) of the ACA, and Section 1866 (j) of the Social Security Act (the Act). CMS implemented these requirements with federal regulations at 42 CFR Part 455 subpart E. These regulations were published in the Federal Register, Vol. 76, February 2, 2011, and were effective March 25, 2011. This regulation, at 42 CFR 455, requires that all participating providers be screened according to their categorical risk level, upon initial enrollment and upon re-enrollment or revalidation of enrollment. States must submit a State plan amendment (SPA) to CMS for review and approval by April 1, 2012 to provide assurances that they will comply with the Federal regulations at 42 CFR 455 Subpart E. Also, see relevant guidance on Provider Terminations.
What is a SPIA?
State Program Integrity Assessment (SPIA) The State Program Integrity Assessment (SPIA) is the CMS first national data collection on state Medicaid program integrity activities for the purposes of program evaluation and technical assistance support. CMS will use the data from the SPIA to develop descriptive reports for each state, ...
Oversight Activities
We undertake various oversight activities to ensure that Medicaid dollars are spent appropriately and accurately. For additional information, see our 5-year, Comprehensive Medicaid Integrity Plan (PDF) for FYs 2019-2023 to protect taxpayer dollars in the Medicaid program and CHIP by combatting fraud, waste, and abuse.
Educational Efforts
We provide a variety of educational resources online to help states, health plans, providers, and others in the fight against fraud, waste, and abuse. These resources cover important topics and best practices to support state program integrity staff.
Medicaid Integrity Institute
We provide training year-round to State Medicaid Program Integrity personnel through the Medicaid Integrity Institute.
Learn More
Comprehensive Medicaid Integrity Plan for FYs 2019-2023 (PDF) – Read our detailed plan to protect taxpayer dollars in the Medicaid program and CHIP by combatting fraud, waste, and abuse.
Report Suspected Fraud, Waste, and Abuse
Medicaid fraud, waste, and abuse can happen at the provider, supplier, and beneficiary level. Because each state manages its own Medicaid program, you should contact your state to report suspicious activity. You can also learn how to report Medicare fraud, waste, or abuse.
Stay in Touch
Contact us by email with questions or suggestions at Medicaid_Integrity_Program@cms.hhs.gov.
What is Medicare Integrity Program?
1893 . [ 42 U.S.C. 1395ddd] (a) Establishment of Program.— There is hereby established the Medicare Integrity Program (in this section referred to as the “Program ”) under which the Secretary shall promote the integrity of the medicare program by entering into contracts in accordance with this section with eligible entities, or otherwise, to carry out the activities described in subsection (b).
Can Medicare contractors use extrapolation?
A medicare contractor may not use extrapolation to determine overpayment amounts to be recovered by recoupment, offset, or otherwise unless the Secretary determines that—. (A) there is a sustained or high level of payment error; or. (B) documented educational intervention has failed to correct the payment error.
