Medicare fraud costs the United States government hundreds of millions of dollars each year. CMS works with other government agencies and law enforcement organizations to protect the Medicare Program from fraud and abuse. The following information provides you with important information about fraud and abuse as well as the government agencies responsible for protecting the Medicare Trust Fund.
The primary goal of ZPIC/UPIC is to investigate instances of suspected fraud, waste, and abuse. Functions of the ZPIC/UPIC include:
National Government Services refers all suspected fraud to the ZPIC/UPIC for additional investigation. This may include results found from:
The following table lists all ZPIC/UPIC, their zones, and states included in each zone:
ZPIC/UPIC | Zone | States in Zone |
---|---|---|
Safeguard Services
|
1 | California, Hawaii, Nevada, American Samoa, Guam, and the Mariana Islands |
NCI AdvanceMed | 2 |
Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming
|
NCI AdvanceMed (UPIC) | Midwestern | Minnesota, Missouri, Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Nebraska, Ohio, Wisconsin
|
Health Integrity | 4 | Colorado, New Mexico, Texas, and Oklahoma |
NCI AdvanceMed | 5 | Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, North Carolina, South Carolina, Virginia, West Virginia |
Safeguard Services | Northeastern | Pennsylvania, New York, Delaware, Maryland, D.C., New Jersey, Massachusetts, New Hampshire, Vermont, Maine, Rhode Island, Connecticut |
Safeguard Services | 7 | Florida, Puerto Rico, Virgin Islands |
All fraud cases developed by the ZPICs/UPICs are referred to the OIG for consideration and initiation of criminal or civil prosecution, civil monetary penalty, or administrative sanction actions. When the ZPICs/UPICs determines that a situation is not fraud, they refer the case back to National Government Services for additional provider education, medical review, or other appropriate action.
Fraud is the intentional deception or misrepresentation that an individual:
Examples of fraudulent behavior:
Abuse involves incidents or practices that are:
Abuse can be identified when individuals unintentionally follow practices that result in unnecessary Medicare Program costs. Abusive practices may develop into fraud and be prosecuted as such.
Examples of abuse include:
One of the most important tools in helping prevent fraud is the reporting of suspected fraudulent activities by concerned employees or beneficiaries. The OIG maintains a hotline as a confidential means for reporting suspected fraud. If you suspect fraud, please contact the OIG using any of the following options:
Phone: 800-HHS-TIPS (800-447-8477)
Fax: 800-223-8164 (limit to ten pages please)
Email: HHSTips@oig.hhs.gov
Mailing address:
Office of the Inspector General
HHS TIPS Hotline
P.O. Box 23489
Washington, DC 20026
If you are attempting to report specific information proving Medicare fraud, please provide as much identifying information as possible. This may include the suspected individual’s name, address, and phone number, as well as any other details regarding the allegation.
Look for additional information from CMS about How to Report Fraud and Suspected Fraud or on the OIG Hotline Operations web page.
The Department of Health and Human Services OIG has developed A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse. The Roadmap summarizes the five main federal fraud and abuse laws (the False Claims Act, the Anti-Kickback Statute, the Stark Law, the Exclusion Statute, and the Civil Monetary Penalties Law) and provides tips on how physicians should comply with these laws in their relationships with payers (like the Medicare and Medicaid programs), relationships with vendors (like drug, biologic, and medical device companies), and relationships with fellow providers (like hospitals, nursing homes, and physician colleagues).
CMS produced two fraud prevention training modules currently available on the Medscape website. These modules provide key information to health care practitioners and professionals on how they can assist CMS in preventing fraud and abuse, as well as highlight CMS’ efforts to fight fraud and abuse and explain how health care professionals can be part of these efforts.
A total of 1.25 hours of continuing medical education (CME) credits can be earned for any Medscape user registered as a doctor or health care professional. Medscape accounts are free, and users do not have to be health care professionals to register for them. Register for a free Medscape account at https://profreg.medscape.com/px/registration.do.