# Presentation: 249666

## 5th National Health Care Fraud and Abuse Control Program ConferenceProgram Safeguard Contractors: The Future of Benefit Integrity

- Lisa Zone
- Acting Director, Division of Benefit Integrity & Law Enforcement Liaison
- September 2002

## Medicare Program Overview

- CMS largest purchaser of health care services in the United States.
- By FY 2003 our programs are projected to serve approximately 79 million beneficiaries.
- Our programs account for more than one of every three dollars spent on health care in the US.
- Second to only Social Security in the level of Federal Spending.

## A Historical View:Program Safeguard Activities

## Program Safeguards in the 1990s

- A time of awakening.
- Providers draining the Medicare Trust Funds without:
- providing services;
- accurately coding for provided services;
- operating a legitimate place of business; or
- complying with program rules.

## Program Safeguards in the 1990s

- CMS cracked down on fraud and abuse.
- Operation Restore Trust Initiative:
- More intense review of providers.
- More on-site presence.
- More collaboration with law enforcement.
- More diligence.

## Program Safeguards in the 1990s

- Our effectiveness was evident.
- Slowed growth in a variety of provider groups: home health and CMHCs.
- Increased fines, penalties and convictions of unscrupulous providers.
- More information sharing and more effort on preventing, as well as detecting fraud and abuse.

## Program Safeguards in the 1990s

- CMS strengthened many administrative tools:
- Statistical sampling;
- Consent settlement;
- Building the Medicare Exclusion Database and the Fraud Investigation Database; and
- Linking medical review and provider enrollment to fraud activities.

## Program Safeguards on the 2000s

- Pay It Right.
- Ensure proper payments for medically necessary services, to legitimate providers, for covered services, provided to eligible beneficiaries.

## Program Safeguards in the 2000s

- Recognize that the vast majority of the over 1 million providers participating in the Medicare program are honest.
- Focus on prevention and committed some program integrity resources to provider education.
- Focus efforts on the relatively small number of fraudulent or abusive providers.

## Program Safeguards in the 2000s

- CMS is not soft on fraud.
- Benefit Integrity funding increased by:
- 10.16% in FY 2000,
- 5.80% in FY 2001, and
- 10.30% in 2002

## Program Safeguards in 2002

- We have the attention of providers across the country.
- A community in a state of fear.
- The era of compliance.

## Program Safeguards in 2002

- Work with the provider community to promote compliance.
- Model Compliance Plans
- Customer Service
- Differentiating between fraudulent providers and honest billing errors – establish balance.

## Program Safeguard Contractors 

## Program Safeguard Contractors 

- _Background:_
- In 1996, Congress enacted HIPAA and the Medicare Integrity Program.
- Created authority for CMS to contract with other than Medicare Carriers and Fiscal Intermediaries (FIs) to perform certain payment safeguard activities.

## Program Safeguard Contractors

- _May1999:_  CMS created a Multiple Award Contract schedule and awarded Indefinite Delivery, Indefinite Quantity contracts to 12 PSCs to perform some or all of the following program integrity functions:
- Medical review
- Benefit integrity
- Cost report audit
- Data analysis
- Provider education

## The 12 PSCs

- AdvancedMed (formerly DynCorp.)
- Aspen Systems Corporation
- Cahaba Safeguard Administrators
- Computer Sciences Corporation (CSC)
- Electronic Data Systems Corp (EDS)
- IntegriGuard a Division of CMRI

## The 12 PSCs

- LifeCare Management Partners, Inc.
- Mutual of Omaha
- Reliance Safeguard Solutions, Inc.
- Science Applications Intl. Corp (SAIC)
- TriCenturion, LLC
- Trust Solutions, LLC

## PSC Implementation Strategy

- Be Opportunistic.
- Test different PSC workload configurations.
- Benefit Integrity Support Center - EDS
- Western Integrity Center - CSC
- Region A DMERC PSC - TriCenturion
- North Carolina PSC – Cahaba
- Ohio/West Virginia PSC – Advanced Med

## PSC Implementation Strategy

- Begin proactively transitioning the fraud and abuse detection and prevention work to PSCs.
- Adopt outcomes-based contracting strategy.
- Establish outcomes not processes.
- All contractors permitted to innovate when developing program safeguard tools in order to achieve intended outcomes.
- Contracts provide incentives for good work through profit and rewards.

## Outcomes-Based Approach

- _Medicare Carriers and FIs_:
- Minimize the fee-for-service claims payment error rate.
- Measured according to the Comprehensive Error Rate Testing Program.
- _PSCs:_
- Minimize fraud and abuse in the Medicare program.

## PSC Implementation Schedule

- August 1, 2002 Transition
- CIGNA
- October 1, 2002 Transition
- National Heritage Insurance Company (NHIC)
- TrailBlazer
- United Government Services (UGS)
- January 1, 2003 Transition
- Blue Cross Blue Shield of Alabama
- First Coast Service Options
- Palmetto GBA
- Empire Blue Cross Blue Shield

## PSC Implementation Strategy

- Next Steps:
- Expand PSC task orders to include additional states or complimentary A or B workloads.
- Compete work in remaining FIs and Carriers.
- Evaluate expanding the model to DME Regional Carriers.
- Consider re-alignment of PSC work to create more geographically-based contractors.

## PSC Coverage

- <date/time>

- Mutual of Omaha’s FI work and the RHHI work of UGS, Cahaba, and Palmetto are not shown, but they will be covered by a PSC.
- NOTE:  In the red colored states, more than one PSC may be operating- one for Part A and one for Part B.

**Hawaii**

**Guam**

**Part A Only**

**Part B Only**

**Part A & B **

**All of NY Part A workload will transition.  Western NY, Part B is not included as part of the proposed implementation strategy**

**PSC Coverage**
**Post Implementation 2003**

## Program Safeguard Contractors

- A Time of Change
- How will the PSCs work with the Carriers and Fiscal Intermediaries?
- Continuum of Cases
- Joint Operating Agreement
- Harkin Grantee Tracking System

## The Future of Benefit Integrity

## Future Benefit Integrity Efforts

- Integrate providers’ compliance efforts.
- Implement PSCs.
- Continue and improve core work.
- Strengthen administrative tools.

## Our Core Work: Benefit Integrity 

- The most prevalent allegations of fraud reported have been as follows:
- Accepting/Soliciting Bribes/Gratuities/Rebates/Discounts
- Medicare/Medicaid Kickbacks
- Billing for Services Not Rendered
- Duplicate Billing
- Overutilization
- Services Not Provided

## Strengthening Administrative Tools:  MED and FID

## Medicare Exclusion Database

- Builds off of the OIG exclusion database.
- Standardizes formatting and data fields.
- Enables linkages to other CMS databases like OSCAR and PECOS.
- Enables Medicare contractors to integrate information into their claims processing systems so no Medicare payments to excluded providers.

## Medicare Exclusion Database

- Federal Register notice of a new system of records published on February 26, 2002.
- The MED was distributed for the first time in mid-April to all Medicare contractors.
- We are also working to make the files available to the Medicaid State Agencies.

## Fraud Investigation Database

- First created in 1996, first nation-wide system devoted to Medicare and Medicaid fraud and abuse data accumulation.
- Improvements:
- Create a Windows based environment.
- CMS has a new contractor – AMS.
- Expect FID updates to be within the next month.

## Fraud Investigation Database

## Fraud Investigation Database

## Fraud Investigation Database

## Fraud Investigation Database

## Thank YouQuestions ?