- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 3: Fraud and Abuse
Program Safeguard Contractor/Zone Program Integrity Contractor
The primary goal of the PSC/ZPIC is to:
- identify cases of suspected fraud;
- develop them thoroughly and in a timely manner; and
- take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid and any mistaken payments are recouped.
National Government Services refers all suspected fraud to the PSC/ZPIC for additional investigation. This may include results found from provider medical review, beneficiary complaints, or through data analysis results. The PSCs/ZPICs responsible for National Government Services investigations are:
- AdvanceMed
- Cahaba Safeguard Administrators
- Safeguard Services
All fraud cases developed by the PSCs/ZPICx are referred to the OIG for consideration and initiation of criminal or civil prosecution, civil monetary penalty, or administrative sanction actions. When the PSC 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.
Provider Actions to Prevent Fraud and Abuse
Medicare has become big business and has attracted, as big businesses sometimes do, a few unethical individuals/providers. As such, honest health care providers must protect their organization from any potentially inappropriate activities. Use the following suggestions to ensure that you or your provider do not fall victim to potentially fraudulent activities:
- Stay informed of, and follow Medicare regulations, policies, and guidelines as they relate to the particular type of organization. It has been demonstrated that many inappropriate activities could have been avoided if the provider understood the Medicare regulations that apply to their organization.
- Ensure that those individuals or entities that are authorized to bill and/or receive payment on behalf of the provider have the appropriate knowledge and expertise to deal with Medicare.
- Distribute Medicare information and training materials to all staff members and facility contractors who are involved in any of the processes resulting in a service being billed to Medicare. This includes, but is not limited to personnel in administration, registration, clinical areas, clinical support areas, billing, finance, and medical records.
- Ensure that any document filed with the Medicare Program is accurate and meets the appropriate standards (e.g., claims, medical records, cost reports, applications, etc.).
- Understand and monitor the terms of employment or contracts to ensure that the provider is not in violation of any law or regulation governing Medicare.
- Ensure that there are no violations of laws or regulations when conducting business with individuals or entities outside of the provider’s organization.
- Institute an effective compliance program using OIG guidelines. This is not a Medicare requirement; however, it is an effective safeguard for the provider.
If you suspect any type of fraudulent activity, you should report it to National Government Services through the Provider Contact Center.
The OIG Hotline may also be called at 1-800-HHS-TIPS (1-800-447-8477).
Revised 1/2021