1. Question: What is the difference between fraud and abuse?
Answer: Fraud is the intentional deception or misrepresentation of facts that an individual or an organization perpetrates for the purpose of gaining an otherwise unauthorized or illegitimate benefit for himself/herself, some other person, or an organization. Abuse involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments. The real difference between fraud and abuse is the person's intent. Both have the same impact: they detract valuable resources from the Medicare Trust Fund that would otherwise be used to provide care to Medicare beneficiaries.
2. Question: What is the Program Safeguard Contractor's (PSC's) or Zone Program Integrity Contractor’s (ZPIC’s) role in fighting Medicare Fraud and Abuse?
Answer: The role of the Program Safeguard Contractor or Zone Program Integrity Contractor is to help address fraud, waste and abuse by performing regional Medicare data analysis, complaint resolution and investigative activities. These and other techniques are also used to identify Medicare program weaknesses and vulnerabilities.
3. Question: What are some common situations that should be referred to the PSC or ZPIC?
Answer: The acceptance or offering of “Kickbacks”, the routine waiver of co-payments, falsifying certificates of medical necessity, plans of care and other records, billing for services not rendered, misrepresenting the diagnosis to justify payment, and beneficiaries sharing Medicare cards are just some of the more common schemes.
4. Question: How do I know if there is suspected fraud and how would I report it?
Answer: Review your Medicare Summary Notice (MSN) when you receive it and make sure you understand all of the items listed. If you don’t remember a procedure that is listed, you should first call your physician, provider, or supplier that is listed on the MSN. Many times a simple mistake has been made and can be corrected by your physician, provider, or supplier’s office when you call. If your physician, provider, or supplier’s office does not help you with the questions or concerns about items listed on your MSN and you still suspect Medicare fraud or if you cannot call them, you should call or write the Medicare company that paid the claim. The name, address, and telephone number are on the MSN you receive, which shows what Medicare paid. You can also call 1-800-Medicare or 1-800-633-4227.
Before contacting the Medicare claims processing company, carefully review the facts as you know them and as shown on the MSN. Write down:
• The provider's name and any identifying number you may have.
• The item or service you are questioning.
• The date on which the item or service was supposedly furnished.
• The amount approved and paid by Medicare.
• The date of the MSN.
• The name and Medicare number of the person who supposedly received the item or service.
• The reason you believe Medicare should not have paid.
5. Question: What is the difference between the PSC or ZPIC and the Affiliated Contractor (AC) or Medicare Administrative Contractor (MAC)?
Answer: The ACs and MACs are responsible for all other functions not specifically assigned to the PSC or ZPIC by the Statement of Work, including claims processing, customer service, select pre- and all post-payment medical review functions, appeals, provider enrollment, financial accounting, Medicare Secondary Payer (MSP) and related provider education and beneficiary outreach activities. The ACs and MACs are also responsible for referring any suspected fraudulent or abusive situations or patterns by providers or beneficiaries in the Medicare program to the PSC or ZPIC.
6. Question: How does the PSC or ZPIC differ from the Quality Improvement Organization (QIO)?
Answer: QIOs are focused more on quality improvement projects in relation to medical review, medical necessity and quality of care issues. Unlike the PSCs or ZPICs, the QIOs are not charged with proactively identifying fraud. However, the QIO is permitted to make referrals to the PSC or ZPIC for benefit integrity issues. Likewise, the PSC or ZPIC may refer cases to the QIO for medical necessity and quality of care issues.
7. Question: What is the difference between a Benefit Integrity PSC or ZPIC and the CERT PSC?
Answer: The Comprehensive Error Rate Testing (CERT) Program produces national, contractor specific, service specific and provider type paid claim error rates. Systematic random samples of claims from the ACs or MACs are periodically reviewed by the CERT in order to evaluate the accuracy of Medicare Fee-for-Service payments.
8. Question: How does a case get referred to a PSC or ZPIC?
Answer: Cases typically get referred from the ACs or MACs resulting from beneficiary/provider and whistleblower complaints. Cases may also be referred from the OIG Hotline and CMS Fraud Alerts.
9: Question: How do I know where to send Medical Records when requested?
Answer: You may receive requests for copies of medical records from the ACs or MACs, the CERT, or the PSC or ZPIC. Letters from each entity will be sent on letterhead for identification purposes with the appropriate contact information contained therein. Any of these record requests should be returned within the specified time period.