On July 29, 2011, the Congressional Research Service (CRS) issued a report entitled, “Medicare Program Integrity: Activities to Protect Medicare from Payment Errors, Fraud, and Abuse.”  The report sets forth an overview of Medicare program activities including discussion on, among other things, the background of Medicare health care fraud, a summary of CMS’s program integrity activities, a description of the relationship between private contractors and federal law enforcement agencies in overseeing Medicare program integrity, and recent program integrity initiatives.

The report provides a status update with respect to CMS program integrity contractors and highlights the six core program integrity activities that such contractors coordinate:

  1. Provider auditing;
  2. Medical necessity claims review;
  3. Fraud investigations;
  4. Medicare secondary payer activities;
  5. Provider education on Medicare billing procedures; and
  6. Identification of Medicare and Medicaid improper billing practices (i.e., Medicare-Medicaid Data Match Program).

Once the CMS program integrity contractors identify suspected fraud, they refer the cases to Medicare administrative contractors to address overpayment issues, and where appropriate, to the Department of Health and Human Services Office of Inspector General and the Department of Justice for further investigation and prosecution.  Program integrity and anti-fraud resources increased from an estimated $0.9 billion in FY 1999 to approximately $1.9 billion in FY 2010, and the number of fraud enforcement actions for new civil and criminal actions have more than quadrupled through FY 2010.

The report is available by clicking here.