The Centers for Medicare and Medicaid Services (CMS) will undertake new efforts to fight fraud and abuse in the Medicare program. The Agency announced that it is consolidating its efforts with new program integrity contractors that will analyze Medicare billing patterns. These contractors will focus on companies and individuals whose billings for Medicare services are higher than the majority of providers and suppliers in the community. The Agency is also examining Medicare billings in seven at-risk states: California, Florida, Illinois, Michigan, New York, North Carolina and Texas. The effort will focus on durable medical equipment companies that inappropriately bill Medicaid or Medicare for equipment, such as wheelchairs and oxygen supplies. The new efforts include:

  • Conducting more stringent reviews of new DMEPOS suppliers' applications, including background checks;
  • Making unannounced site visits to double check that suppliers and home-health agencies are actually in business;
  • Verifying claims submitted by physicians who order a high number of certain items or services by sending follow-up letters to these physicians; and
  • Identifying and visiting high-risk beneficiaries to ensure they are appropriately receiving the items and services for which Medicare is being billed.

For claims not reviewed before payment is made, CMS is implementing further medical review of submitted DMEPOS claims by one of the new recovery audit contractors (RACs). The RACs review paid claims for all Medicare Part A and B providers to ensure their claims meet Medicare requirements.

Significantly, CMS is consolidating the work of Medicare's program safeguard contractors (PSCs), and the Medicare Drug Integrity Contractors (MEDICs) with new Zone Program Integrity Contractors (ZPICs). The new contractors will eventually be responsible for ensuring the integrity of all Medicare-related claims. The first two ZPIC contracts were awarded to Health Integrity, LLC for Zone 4, which covers Texas, New Mexico, Colorado, and Oklahoma, and SafeGuard Services, LLC for Zone 7, which includes Florida, Puerto Rico and the U.S. Virgin Islands. For more information, please click here and here.