MEDICARE INTEGRITY PROGRAM The CMS tasked a Medicare contractor to develop and pilot test a method for estimating a fraud rate among providers in a contractor's service area. The pilot program includes drawing a random sample of claims using the CERT platform, contacting beneficiaries, and conducting interviews. The beneficiary interviews are considered critical in determining whether the provider actually delivered the stated services on the claim. However, due to the complexity of measuring fraud, numerous other indicators are required in order to produce a reliable estimate. The CMS has been examining alternative proposals for nationwide feasibility and a model fraud rate program will be implemented in FY 2002, contingent upon funding from the Health Care Fraud and Abuse Control (HCFAC) account. Coordination: We will continue to work with OIG, our PSC contractors, and our Data Source(s): Monthly reports are received from the Contractor to verify that they have complied with the phases proposed in the CERT implementation timetable for the Medicare contractors. The first CERT error rate and PCR reports for the four DMERCS are to be published in January 2002. These same reports will be published for the carriers on the VMS system in April 2002 and in August 2002 for the carriers on the EDS MCS system. The first national error and PCR rates will be published for FY 2003. Verification and Validation: The CMS verifies Contractor performance and data through its Contractor Performance Evaluation program. MEDICARE INTEGRITY PROGRAM Performance Goal MIP3-01 Improve the Effectiveness of Program Integrity Activities through the Successful This goal was designed to monitor the implementation and measure the effectiveness of By developing and publicly distributing the Comprehensive Plan, CMS reinforced its commitment to fighting fraud and abuse in the Medicare and Medicaid programs. Promoting the integrity of Medicare and Medicaid is a top priority for CMS. As these programs have grown in size and complexity, so have the importance and challenges of that responsibility. Achieving program integrity now requires the active involvement of every component of CMS, and effective coordination with our partners, including contractors, providers, beneficiaries, law enforcement, and others. Our overarching program integrity goal is straightforward. We strive in every case to pay the right amount, to a legitimate provider, for covered, reasonable, and necessary services, provided to an eligible beneficiary: to pay it right the first time. In order to achieve this overarching goal, CMS's Comprehensive Plan addressed ten areas. Five of the initiatives in the Comprehensive Plan addressed program management vulnerabilities and the other five addressed specific service areas that we believed were vulnerable to fraud and abuse. The CMS began work on these initiatives in October 1999 and we expect to have these initiatives fully implemented in FY 2001While performance is being assessed throughout the implementation process, it is critical to monitor the overall effectiveness of each initiative throughout FY 2001. To MEDICARE INTEGRITY PROGRAM assist us in evaluating the effectiveness of our efforts, we developed specific performance measures for each of the ten Comprehensive Plan initiatives. MEDICARE INTEGRITY PROGRAM Comprehensive Plan Sub-Goal Updates (1 ) Increase the Effectiveness of Medical Review and Benefit Integrity Activities -Plans for improvement in this area include increasing the overall level of medical review; hiring outside contractors to evaluate medical review practices and workloads across contractors; developing improved performance standards for contractor program integrity activities; and, conducting training for CMS and contractor staff to enhance the quality of fraud case referrals. Goal (1a): FY 2001 Target: Improve quality of medical review and benefit integrity outcomes To develop and fully implement Medicare carrier and fiscal Update Information: New Contractor Performance Evaluation (CPE) guidelines that focus on measuring quality outcomes have been developed and fully implemented. These guidelines were first tested during FY 1999. They were revised in FY 2000 and further streamlined for use in FY 2001. Goal Met. Goal (lb): Baseline: FY 2001 Target: Develop new methods to reduce the percentage of improper payments made under the Medicare fee-for-service program. The three proposed methods described in the target are new. To implement the Provider Compliance Rate (PCR); to implement the refined CFO audit methodology to produce a Update Information: See goal MIP2-03 update. subnational error rate; and to implement a fraud rate program. (2) Implement the Medicare Integrity Program - The CMS is using its more flexible contracting authority to begin contracting with new entities called Program Safeguard Contractors (PSCs). The CMS has awarded 13 PSC contracts and between September and November of 1999 CMS awarded six program integrity task orders to these new contractors. Goal: Baseline: FY 2001 Target: Implement a fully functioning Program Safeguard Contractor Currently none of the three PSC modes are fully implemented. Update Information: We have implemented the three PSC operational models and have awarded the contract for the fourth PSC model. Goal Met. |