Department of Health and Human Services 
 
 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
T M -M
H  E  EDICARE EDICAID 
(M -M ) D M
EDI EDI   ATA  ATCH 
P  
ROGRAM 
 
     
 
Daniel R. Levinson  
Inspector General 
 
April 2012 
OEI-09-08-00370  EXECUTIVE SUMMARY:  THE MEDICARE-MEDICAID (MEDI-MEDI) DATA 
MATCH PROGRAM 
OEI-09-08-00370 
 
WHY WE DID THIS STUDY  
 
The Medicare-Medicaid Data Match program (Medi-Medi program) enables program safeguard 
contractors (PSC) and participating State and Federal Government agencies to collaboratively 
analyze billing trends across the Medicare and Medicaid programs to identify potential fraud, 
waste, and abuse.  Participation is optional.  The Social Security Act mandates that the 
Medi-Medi program increase the effectiveness and efficiency of the Medicare and Medicaid 
programs through cost avoidance (i.e., prepayment denials); savings; and recoupment of 
fraudulent, wasteful, or abusive expenditures.   
 
HOW WE DID THIS STUDY 
 
We analyzed data collected from the Centers for Medicare & Medicaid Services (CMS), PSCs, 
State Medicaid program integrity agencies, and other Federal and State agencies participating in 
the Medi-Medi program.  The period of our review was 2007 and 2008. 
 
WHAT WE FOUND 
 
The Medi-Medi program produced limited results and few fraud referrals.  During 2007 and 
2008, the programin which 10 States had chosen to participatereceived $60 million in 
appropriations and it avoided and recouped $57.8 million.  The program produced 66 referrals to 
law enforcement, and law enforcement accepted 27 of these.  Among the 10 participating States 
collectively, each State averaged 2.8 Medicare referrals to law enforcement per year; law 
enforcement accepted an average of 1.15 referrals per State per year.  In comparison, each State 
averaged 0.5 Medicaid referrals to law enforcement per year; law enforcement accepted an 
average of 0.2 referrals per State per year.  Also, State Medicaid programs received less benefit 
from the Medi-Medi program than Medicare received.  Of the $46.2 million total in Medicare 
and Medicaid expenditures recouped through the program during 2007 and 2008, more than 
three-quarters$34.9 millionwas recouped for Medicare.   
 
WHAT WE RECOMMEND 
 
We recommend that CMS reevaluate the goals, structure, and operations of the Medi-Medi 
program to determine what aspect of the program, if any, should be part of CMSs overall 
program integrity strategy.  CMS concurred with our recommendation.  CMS commented that 
since the period of our review, it has made significant strides in enhancing the effectiveness of 
the Medi-Medi program.  However, since our period of review, CMS has not provided any data 
to illustrate enhanced effectiveness, such as the number of referrals, accepted referrals, and the 
actualnot potentialMedicare and Medicaid expenditures avoided and recouped through the 
program.  These data would enable Congress to make an informed decision whether to continue 
funding the program and enable State and Federal agencies to make an informed decision 
whether to participate. TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................8 
Findings......................................................................................................14 
Although most PSCs performed all of the required tasks, the 
Medi-Medi program produced limited results and few fraud  
referrals ..........................................................................................14 
State Medicaid programs received less benefit from the                     
Medi-Medi program than Medicare received ................................17 
Limitations in the administration of the Medi-Medi program     
may have diminished its potential..................................................18 
Recommendation .......................................................................................21 
Agency Comments and Office of Inspector General Response .....22 
Appendixes ................................................................................................23 
A:  Sources for Centers for Medicare & Medicaid Services 
Requirements for the Medicare-Medicaid Data Match Program ...23 
B:  Required Tasks Listed in the Statement of Work and 
Documentation Analyzed To Determine Whether Tasks Were 
Performed .......................................................................................24 
C:  Analysis Results of Program Safeguard Contractors                   
Performance of Selected Tasks in the Statement of Work for           
the Medicare-Medicaid Data Match Program ...............................27 
D:  Agency Comments ...................................................................29 
Acknowledgments......................................................................................32 
 
  OBJECTIVES 
To determine:   
1.  Whether program safeguard contractors (PSC) performed the required 
tasks for the Medicare-Medicaid Data Match program (Medi-Medi 
program). 
2.  To what extent the Medi-Medi program identified fraud, waste, and 
abuse. 
BACKGROUND 
Medicare-Medicaid Data Match Program 
The Medi-Medi program enables PSCs and participating State and Federal 
Government agencies to collaboratively analyze billing trends across the 
Medicare and Medicaid programs to identify potential fraud, waste, and 
abuse.  The PSCs primary goal with regard to the Medi-Medi program is 
to identify cases of suspected fraud and take immediate action to ensure 
that monies are not inappropriately paid out and that any inappropriate 
payments are recouped.1  The purpose of analyzing Medicare and 
Medicaid claims data collectively is to detect aberrant billing patterns that 
may not be evident when analyzing the data separately. 
Funding for the Medi-Medi program.  After the Centers for Medicare  
& Medicaid Services (CMS) implemented an initial pilot program in one 
State in 2001, nine additional States opted to participate.2  Between fiscal 
years (FY) 2001 and 2005, the program received approximately 
$30 million in funding from a combination of Health Care Fraud and 
Abuse Control funds and Federal Bureau of Investigation funds.3  The 
Deficit Reduction Act (DRA) of 2005 established and funded an expanded 
Medi-Medi program, appropriating funding on an FY basis starting in 
2006.  In FY 2006, funding was $12 million.  By FY 2009, funding had 
increased to $48 million.  Starting in FY 2010 and for each subsequent 
 
1
 CMS, Medicare Program Integrity Manual, Pub. 100-08, ch. 4,  4.2.  Accessed at 
https://www.cms.gov/manuals/downloads/pim83c04.pdf on October 25, 2010.  
2
 In 2003, Florida, Illinois, New Jersey, North Carolina, Pennsylvania, and Texas joined the program.  In 2004, 
Ohio and Washington joined, followed in 2005 by New York.  CMS, Medicare-Medicaid Data Match Program 
(Medi-Medi) Policies and Procedures Manual (Medi-Medi PPM), August 20, 2007, p. 3. 
3
 The Health Insurance Portability and Accountability Act of 1996 established a national Health Care Fraud and 
Abuse Control Program under the joint direction of the Attorney General and the Secretary of Health and 
Human Services (HHS) (acting through the Inspector General).  The program was designed to coordinate 
Federal, State, and local law enforcement activities with respect to health care fraud and abuse.  HHS and 
Department of Justice, Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2010,  
p. 1.  Accessed at http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2010.pdf on June 29, 2011.    
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  1  year, the DRA has funded the program at $60 million per year.4  During 
the period of our review2007 and 2008$60 million was appropriated 
to fund the program:  $24 million in 2007 and $36 million in 2008.5 
Authorities.  Section 1893(g) of the Social Security Act (SSA) sets forth the 
requirements for conducting the Medi-Medi program.6  Section 1893(g) 
requires that certain program integrity functions be performed.  PSCs are 
expected to perform these functions, which consist of:    
  identifying program vulnerabilities by using computer 
algorithms to look for payment anomalies (including billing or 
billing patterns identified with respect to service, time, or 
patients that appear suspect or otherwise implausible); 
  working with States, the Attorney General, and the Inspector 
General of HHS to coordinate actions to protect the Federal and 
State shares of Medicare and Medicaid expenditures; and 
  increasing the effectiveness and efficiency of Medicare and 
Medicaid through cost avoidance (i.e., prepayment denials); 
savings; and recoupment of fraudulent, wasteful, or abusive 
expenditures.   
In addition, section 1893(g)(1)(B) of the SSA requires that, no less 
frequently than quarterly, any data and statistics collected by the        
Medi-Medi program be made available to the Attorney General, the 
Director of the Federal Bureau of Investigation, the Inspector General of 
HHS, and the States (including the Medicaid Fraud Control Units). 
 
Medi-Medi Statement of Work tasks.  To address the requirements in 
section 1893(g) of the SSA, CMS requires PSCs to perform program 
integrity tasks listed in a Medi-Medi Statement of Work (SOW).7  
However, in those SOWs, CMS does not impose minimum output 
standardsnational or otherwiserelating to the extent to which PSCs 
make referrals to Federal or State law enforcement agencies or the amount 
of fraud, waste, and abuse expenditures avoided or recouped.8  For each of 
the 10 States that participated during 2007 and 2008, CMS awarded a 
 
4
 P.L. 109-171  6034.  
5
 DRA  6034.    
6
 Section 6034 of the DRA added section 1893 of the SSA, which permanently established the Medi-Medi 
program at section 1893(g).  P.L. 109-171  6034. 
7 The SOW is a contract between CMS and a PSC.   
8
 PSCs are required to submit a monthly status report to CMS identifying the providers being referred to law 
enforcement and indicating whether those referrals were accepted.  However, according to CMS Medicare 
program integrity staff, the purpose of collecting these data is to provide them upon request to third parties, such 
as Congress, the Government Accountability Office (GAO), and/or the HHS Office of Inspector General.  
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  2  SOW to a PSC.9  CMS awarded 10 individual SOWs among 8 PSCs.  
(One PSC was awarded three SOWs.)  The SOW is incorporated into each 
PSCs broader program integrity task order.  During 2007 and 2008,        
10 SOW tasks were listed:10 
 
1.  Incorporate a project plan that defines the steps and timelines 
for implementing the Medi-Medi program, including 
identifying resource needs and responsible parties to complete 
the implementation steps.        
2.  Incorporate a detailed information technology plan identifying 
how the PSC shall receive, store, safeguard, manipulate, and 
analyze data. 
3.  Submit to CMS a monthly status report reflecting the PSCs 
results from the previous month.  Among other information, the 
report must contain information about Medi-Medi program data 
analysis; providers being referred to law enforcement; the 
status of those referrals (i.e., whether law enforcement accepts 
or declines them); outcome of civil or criminal prosecution or 
administrative action; and the amount of Medicare and/or 
Medicaid expenditures avoided and recouped. 
4.  Develop a joint operating agreement with the State Medicaid 
program integrity agency (and any other necessary parties) to 
establish guidelines, duties, and shared expectations for the 
Medi-Medi program.   
5.  Provide State Medicaid program integrity staff with access to 
matched Medicare and Medicaid data within 4 months of 
executing a computer match agreement.   
6.  Analyze data, including data matching, trending, and statistical 
activities, to enhance the detection and prevention of Medicare 
and Medicaid fraud and abuse.   
7.  Develop and refer potential fraud cases and/or data leads to the 
appropriate State or Federal law enforcement agencies.   
 
9
 CMS is transitioning program integrity work from PSCs to Zone Program Integrity Contractors (ZPIC).  CMS 
began awarding contracts to ZPICs in September 2008.  However, in 2008, the initial transition process 
occurred in only two participating States.  The chief difference between PSCs and ZPICs is that ZPICs cover 
broader geographical areas and multiple parts of the Medicare program, whereas PSCs cover more limited areas 
and scopes. 
10
 The tasks listed in the SOW for each PSC vary, but not substantially.  This list summarizes the 10 tasks 
identified in a SOW.   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  3  8.  Facilitate a quarterly steering committee11 with Federal and 
State agencies participating in the Medi-Medi program, and 
prepare minutes of those meetings.  
9.  Prepare a lessons learned report discussing matching and 
combining Medicare and Medicaid data. 
10. Perform transition activities, working closely with ZPICs to 
ensure that all program integrity activities continue during the 
transition from PSCs to ZPICs.12  Such activities include (but 
are not limited to) transferring medical records, information on 
investigations and on cases referred to law enforcement, and 
other data to ZPICs. 
 
During the first year that CMS awarded Medi-Medi SOWs to PSCs, it 
required them to perform three of these tasksincorporating a project 
plan (task #1), incorporating an information technology plan (task #2), and 
preparing lessons learned reports (task #9)on a one-time basis.  
Because all of the SOWs were awarded prior to 2007, each PSC 
performed those three tasks prior to the period of our review.  With respect 
to task #10performing transition activitiesonly two ZPICs were 
officially awarded SOWs during 2008, according to CMS Medicare 
program integrity staff.13  One of these two ZPICs had previously 
performed tasks under a SOW as a PSC.  The other ZPIC had not, so the 
PSC in that instance was required to perform transition activities.  
Therefore, during 2007 and 2008, nine PSCs were required to perform six 
tasks (tasks #38) and the remaining PSC was required to perform seven 
tasks (tasks #38 and task #10). 
Administration of the Medi-Medi Program 
Even though the purpose of the Medi-Medi program is to address 
vulnerabilities in both Medicare and Medicaid, during 2007 and 2008 the 
Medi-Medi program was administered solely by CMS Medicare program 
integrity staff.14  In February 2010, CMS announced a reorganization.  The 
Medicare integrity program is now administered by the CMS Medicare 
 
11
 The actual schedule is determined jointly by the applicable PSC, the State Medicaid program integrity 
agency, and other participating Federal and State agencies.  
12
 According to Medicare program integrity staff, when a PSC under a SOW is subsequently awarded a SOW 
as a ZPIC, the PSC is not required to perform transition activities.  This task is required only when the SOW is 
awarded to a ZPIC that is an entity different from the preceding PSC.  
13
 Although SOWs were awarded to two ZPICs during 2008, the transition was not completed in 2008.  Thus, 
for our 20072008 period of review, only PSCs performed the SOW tasks.     
14
 Administering the Medi-Medi program includes, but is not limited to, CMSs procuring funding to award 
SOWs to PSCs, providing program guidance, assessing PSCs, entering into contracts with PSCs, and partnering 
with State Medicaid agencies and other applicable Federal and State law enforcement agencies to facilitate the 
program.  CMS, Medi-Medi PPM.  The date of the manual is August 20, 2007.   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  4  Program Integrity Group; similarly, the CMS Medicaid integrity program is 
now administered by the CMS Medicaid Program Integrity Group.  Both of 
these integrity programs fall under the direction of the CMS Center for 
Program Integrity.  Despite the reorganization, the Medi-Medi program 
remains administered solely by Medicarespecifically, by the CMS 
Medicare Program Integrity Group.  For the purpose of this report, we refer 
to this entity as the CMS Medicare program integrity staff, as that was its 
name during the period of our review. 
CMS Medi-Medi program guidance.  The Medi-Medi PPM provides PSCs, 
State Medicaid program integrity agencies, and Federal and State law 
enforcement agencies with Medi-Medi program guidance, which includes 
(but is not limited to) information relating to: 
  identifying the roles and responsibilities of PSCs and participating 
agencies,  
  implementing the Medi-Medi program, 
  data connectivity and sharing, and  
  data matching.  
Law enforcement agencies that typically participate in the Medi-Medi 
program are the Federal Bureau of Investigation, the HHS Office of 
Inspector General, Medicaid Fraud Control Units, and/or State offices of 
Attorneys General (the Medi-Medi partners).15   
The Medi-Medi PPM also identifies activities that should be performed by 
State Medicaid program integrity agencies and Medi-Medi partners.  
Although PSCs receive a portion of the Medi-Medi appropriations from 
CMS, States receive no funding to participate and State participation is 
optional.16  However, for the States that do participate in the Medi-Medi 
program, each States Medicaid program integrity agency is encouraged to 
complete certain ongoing activities to benefit the program.  These include 
(but are not limited to) providing Medicaid policy and data assistance, 
participating in Medi-Medi data work groups, and working on joint 
investigations.17   
For those Medi-Medi partners that do participate, the Medi-Medi PPM 
identifies activities that they should perform.  They generally include (but 
 
15
 For the purpose of this report, these law enforcement agencies will be individually referred to by their proper 
names and collectively referred to as the Medi-Medi partners.  Although other State and Federal law 
enforcement agencies may participate, the Medi-Medi partners are the agencies to which PSCs are required to 
make data and statistics available.     
16
 According to Medicare program integrity staff, the remaining appropriations are used for Medi-Medi 
program expansion, data systems, and a national Medi-Medi coordinator.  
17
 CMS, Medi-Medi PPM, pp. 5-6. 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  5  are not limited to) participating in the steering committee meetings for the 
applicable State, receiving referrals, and providing feedback to the meeting 
attendees about referrals.18 
The Medicare Program Integrity Manual also provides PSCs with 
additional guidance on the Medi-Medi program.19  The manual identifies 
PSC program integrity requirements, such as the processes for sharing 
fraud referrals with Medi-Medi partners.   
Assessments of PSCs.  PSCs are subject to annual assessments by CMS 
Medicare program integrity staff.20  In addition, CMS assigns a contract 
officers technical representative to assess each PSCs performance.  
The 2007 and 2008 Program Safeguard Contractor (PSC) Performance 
Evaluation Guidelines (Evaluation Guidelines) provide guidance for 
assessing PSCs performance under the broader program integrity task order, 
as well as with regard to the tasks applicable to the Medi-Medi SOW.  The 
Evaluation Guidelines provide assessment guidance regarding the following 
six SOW tasks:   
  submitting to CMS a monthly status report (task #3), 
  developing a joint operating agreement (task #4), 
  providing remote user support and access (task #5), 
  performing data analysis (task #6), 
  developing and referring potential fraud cases (task #7), and  
  facilitating a steering committee (task #8). 
The Evaluation Guidelines further require that CMS document its 
assessment findings in its PSC BI [Benefit Integrity] Evaluation Control 
Objectives and Findings Tables (Findings Tables).21  
The Findings Tables are an internal CMS document that contains the 
comprehensive results of each PSCs annual assessment.  The document 
identifies key elements of the required tasks that need to be completed by the 
PSCs.  The Findings Tables contain the review methodology used for rating 
a PSCs performance, as well as the rating score and assessment findings.  
The ratings range from 0 (unsatisfactory) to 5 (outstanding).  CMS 
provides the PSC with an oral summary of the ratings and findings.   
 
18
 CMS, Medi-Medi PPM,  2.    
19
 CMS, Medicare Program Integrity Manual, Pub. 100-08, ch. 4.  Accessed at 
https://www.cms.gov/manuals/downloads/pim83c04.pdf on October 25, 2010. 
20
 HHS, Acquisition Policy Memorandum 200907, p. 5.   
21
 CMS, Program Safeguard Contractor Performance Evaluation Guidelines 2007, p. 45, and CMS, Program 
Safeguard Contractor Performance Evaluation Guidelines 2008,  p. 45.   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  6  Pursuant to the Federal Acquisition Regulation, CMS summarizes the results 
of the Findings Tables in a Standard Contractor Performance Report 
(Performance Report).22  For each assessment of a PSC, CMS submits a 
summary into the National Institutes of Health contractor performance 
system.  The Performance Report contains the actual assessment rating score 
and the summarized findings.  Although the contractor performance system 
is not accessible to the public, PSCs use this system to review their own 
assessments.23   
Current and Planned Sources of Medicare and Medicaid Data 
In 2007 and 2008, PSCs extracted Medicare claims data through the CMS 
National Claims History files and shared system files.  Unlike CMS, 
which collects its Medicaid claims data from each State via the Medicaid 
Statistical Information System (MSIS),24 PSCs obtain Medicaid claims 
data directly from the participating States Medicaid Management 
Information Systems (MMIS) to match them to Medicare data.  For each 
participating State, the State Medicaid program integrity agency receives 
matched Medicare and Medicaid claims data from the PSC.  The matched 
data may also be shared with Medi-Medi partners. 
The One PI System.  A source for Medicare and Medicaid data that is being 
developed by CMS is the One PI System.  (The PI in the name stands for 
Program Integrity.)  According to the Medi-Medi PPM and CMS Medicare 
program integrity staff, the concept of the One PI System is to enable access 
to integrated Medicare and Medicaid data.  The Medi-Medi PPM provides 
guidance on using the One PI System.    
One PI users obtain data from the CMS-managed integrated database 
repository.  As of the date of this report, the repository is fully functional for 
accessing data from Medicare Parts A, B, and D; limited provider data; and 
beneficiary data.25  However, Medicaid data are not yet included.  Until 
CMS can integrate Medicaid data into the repository, the One PI System 
cannot be used to collectively match or analyze Medicare and Medicaid data 
for fraud, waste, and abuse.  The contract to implement the One PI System 
 
22
 Federal Acquisition Regulation  42.1501.   
23
 CMS uses the National Institutes of Health contractor performance system to record PSC performance.  
However, as of September 30, 2010, the National Institutes of Health stopped its service of accepting 
performance information and encouraged users to transition to the Department of Defense Contractor 
Performance Assessment Reporting System. 
24
 States are required to submit all their eligibility and claims data to CMS on a quarterly basis through MSIS.  
CMS uses MSIS to collect, manage, analyze, and disseminate information on eligibles, beneficiaries, utilization, 
and payment for services covered by State Medicaid programs.  SSA  1903(r); CMS, Medicaid Statistical 
Information Statistics (MSIS).  Accessed at http://www.cms.gov/MSIS/ on January 17, 2011.    
25
 The repository provides access to users through a variety of data analysis software tools, such as SAS, 
MicroStrategy, Cognos, Business Objects, and Advantage Suite.    
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  7  was awarded in September 2006, and the system was to be implemented 
within 5 years at a projected cost of $105 million.26 
The Fraud Investigation Database 
The Fraud Investigation Database is a nationwide data entry and reporting 
system designed to track Medicare, Medicaid, and Medi-Medi fraud and 
abuse data.  Under the Medi-Medi program, PSCs are required to enter into 
the database information about PSC-initiated investigations, cases referred to 
law enforcement, and payment suspensions related to fraud and abuse.27  
State Medicaid program integrity agencies, Medi-Medi partners, and other 
Federal and State law enforcement agencies use the database to access the 
information that PSCs enter into it. 
Related Studies  
In 2004, GAO issued a report that, in part, provided information about 
CMSs efforts to support and oversee State program integrity activities, such 
as the Medi-Medi program.28  GAO found that CMS conducted little 
oversight of these activities. 
In 2005, GAO released a report that focused on (1) the level of resources 
CMS applied to helping States prevent and detect fraud and abuse in 
Medicaid and (2) the implications of that level of support for CMS fraud and 
abuse control activities.29  GAO found that the expansion of the Medi-Medi 
data match project was slow, potentially leaving unrealized millions of 
dollars in cost avoidance and cost savings.  GAO concluded that developing 
a strategic plan for Medicaid fraud and abuse control activities would give 
CMS a basis for providing resources that reflect the financial risk to the 
Federal Government.   
METHODOLOGY 
Scope 
This evaluation focused on the PSCs performance under the SOW during 
the period of 2007 and 2008.  We selected this period because CMS had 
completed its own internal assessment of the Medi-Medi program (known as 
 
26
 CMS Medicare program integrity staff and CMS One PI staff.   
27
 CMS, Medicare Program Integrity Manual, Pub. 100-08, ch. 4,  4.11.  Accessed at 
https://www.cms.gov/manuals/downloads/pim83c04.pdf on May 27, 2010.   
28
 GAO, Medicaid Program Integrity:  State and Federal Efforts to Prevent and Detect Improper Payments, 
GAO-04-707, July 2004.  Accessed at http://www.gao.gov/new.items/d04707.pdf on May 26, 2010.     
29
 GAO, Medicaid Fraud and Abuse:  CMSs Commitment to Helping States Safeguard Program Dollars Is 
Limited, GAO-05-858T, June 28, 2005.  Accessed  at http://www.gao.gov/new.items/d05855t.pdf on May 26, 
2010.    
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  8  a lessons learned report) for the period preceding 2007.30  In addition, 
CMS expressed an interest in the results of our independent evaluation from 
2007 and 2008 for its transition from using PSCs for the Medi-Medi 
program to using ZPICs instead.  As of the date of this report, the transition 
is still in process.   
We report whether PSCs performed the SOW tasks required in 2007 and 
2008.  We also report the number of referrals made to law enforcement 
through the Medi-Medi program and the number that were accepted.  In 
addition, we identify the actual dollars associated with Medicare prepayment 
denials and the Medicare and Medicaid dollars recovered.  Finally, we report 
the extent to which CMS assessed PSCs performance under the SOW.   
Data Collection 
We obtained the following from CMS Medicare program integrity staff: 
  sources for CMS requirements for the Medi-Medi program for 2007 and 
2008 (see Appendix A for a list of these documents);   
  documentation (including the Findings Tables and the Performance 
Reports) illustrating the extent to which PSCs performed SOW tasks;  
  documents that PSCs produced as required by 3 of the 10 SOW tasks 
during 2007 and 2008:  monthly status reports (required by task #3), 
joint operating agreements (required by task #4), and quarterly minutes 
(for task #8, which requires PSCs to facilitate a joint steering 
committee);31  
  the number of referrals made to law enforcement and the number that 
CMS identified as being accepted; and 
  the dollars associated with Medicare prepayment denials and/or the 
dollars recovered through each States Medi-Medi activities. 
To validate and supplement the documentation that we obtained from 
Medicare program integrity staff, we:   
  sent questionnaires to and conducted structured in-person interviews 
with CMS Medicare program integrity staff; 
 
30
 Optimal Solutions Group L.L.C., Final Lessons Learned Report (HHSM-500-2006-00165G),               
January 29, 2007.   
31
 Because all of the SOWs were awarded prior to 2007, each PSC had already been required to complete 
tasks 1, 2, and 9 (incorporating a project plan, incorporating an information technology plan, and preparing a 
lessons learned report) and we did not collect these documents during our review.  However, we requested 
that CMS Medicare program integrity staff verify through questionnaires and structured interviews that these 
tasks had been completed. 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  9    conducted structured in-person interviews with CMS One PI staff, an 
official from the Center for Medicaid and State Operations, and contract 
officers technical representatives;32 
  conducted structured in-person interviews with staff from each of the 
PSCs; 
  conducted structured interviews with staff from each of the 10 State 
Medicaid program integrity agencies that participated in the Medi-Medi 
program (conducting 5 of these 10 interviews in person);33 and 
  conducted structured interviews (by telephone) with staff from a total of 
37 of the potential 41 various Medi-Medi partners associated with the   
10 participating States.34 
Data Analysis  
Unit of analysis.  Our unit of analysis is the 10 Medi-Medi SOWs awarded 
to PSCs, which correspond to the participating 10 States.  For ease of 
reporting, we use the term 10 PSCs to represent the 10 SOWs awarded 
among 8 PSCs.   
Analysis of the SOW tasks.  Even though the 2007 and 2008 SOWs included 
10 tasks, we assessed PSC performance related only to the tasks CMS 
required PSCs to continue to perform in 2007 and 2008.  
We reviewed the Medi-Medi program requirements for 2007 and 2008 to 
identify all the requirements related to the SOW tasks.  For each PSC, we 
then reviewed the Findings Tables and Performance Reports to determine 
whether CMS hadas required by the Evaluation Guidelinesdocumented 
the assessments.  We also reviewed responses from our structured interviews 
and questionnaires to supplement and/or validate our determination of 
whether the PSC performed the tasks according to the requirements.   
For a number of SOW tasks, we applied additional data-analysis 
methodologies: 
  For the requirement that each PSC submit to CMS a monthly status 
report (task #3) and develop a joint operating agreement (task #4), we 
reviewed the 2007 and 2008 monthly status reports and joint operating 
agreements.    
 
32
 We interviewed a Center for Medicaid and State Operations official to gain a Medicaid perspective of the 
Medi-Medi program.  Upon enactment of the DRA, the Center for Medicaid and State Operations administered 
the Medicaid integrity program within CMS.   
33
 To reduce travel costs, we conducted interviews and reviewed documentation and/or data at 5 of the 10 State 
Medicaid program integrity locations near PSC locations. 
34
 Although the number of Medi-Medi partners that participated in the interviews varied among States, we 
interviewed at least three Medi-Medi partners from each participating State.  
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  10    For the requirement that each PSC perform data analysis (task #6) and 
develop and refer potential fraud cases (task #7), we reviewed 2007 and 
2008 monthly status reports and CMSs responses to our questionnaires.  
As part of our structured interviews, while onsite at each PSC location, 
we also reviewed various examples of each PSCs data analysis and case 
development.  For the task of performing data analysis, we calculated the 
sum of unique data analysis projects performed by each PSC.  These 
projects included identifying patterns of potential Medicare and/or 
Medicaid fraud and performing data analysis targeted to specific 
providers and/or services.  A PSC may perform data analysis for a unique 
project over several months.  If a PSC reported that it continued to 
perform data analysis for that same project in subsequent months, we 
counted that project for each of those months as one of the unique data 
analysis projects being performed during that month.   
  For the requirement that each PSC facilitate a steering committee 
(task #8), we reviewed minutes from the meetings.   
See Appendix B for documentation and data we analyzed to determine 
whether PSCs performed the required SOW tasks. 
Although CMS rates PSCs performance using a system ranging from 0 
(unsatisfactory) to 5 (outstanding), because of this systems subjective 
nature, we did not attempt to rate PSC performance.  We considered a task 
performed if documentation and/or data existed demonstrating that the task 
was performed. 
Analysis of fraud, waste, and abuse identified through the Medi-Medi 
program.  We analyzed the responses of CMS Medicare program integrity 
staff to our questionnaire to identify the number of Medicare and Medicaid 
referrals made to Federal and State law enforcement agencies and the 
number that were accepted.  In addition, we calculated the amount of 
Medicare and Medicaid expenditures avoided through prepayment denials 
and the amount of dollars recovered.  We limited the scope of this analysis to 
actual dollars recovered, as opposed to potential dollars recovered.   
We report fraud, waste, and abuse expenditures avoided (meaning 
prepayment denials) or recouped (meaning funds recovered).  This 
terminology is consistent with the language in section 1893(g) of the SSA.   
Analysis of the Medi-Medi program assessment process.  For each PSC, we 
reviewed the 2007 and 2008 program requirements.  We then reviewed the 
2007 and 2008 Findings Tables and Performance Reports to determine the 
extent to which CMS recorded its assessment of each PSCs performance of 
the required SOW tasks.  We also reviewed responses from our structured 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  11  interviews and questionnaires to supplement and/or validate our 
determination of the extent of CMSs assessment of PSCs performance.     
Data Limitations 
Each program (Medicare and Medicaid) and each participating State operate 
under different circumstances and/or policies.  For example, each 
participating States Medi-Medi activities are unique to that State, and 
although PSCs are required in their SOWs to refer potential fraud cases to 
State Medicaid program integrity agencies and/or Federal or State law 
enforcement agencies, PSCs do not control what those entities do with their 
referrals.  In addition, there may be more Federal law enforcement agency 
resources available for Medicare than there are State law enforcement 
agency resources available for Medicaid.   
PSCs vary as to how much information on data analysis projects they 
include in their monthly status reports.  In addition, the project descriptions 
they include in these reports are not comprehensive and do not necessarily 
identify the providers; the relevant program (i.e., Medicare or Medicaid); or 
the results or disposition of the projects.  For example, some reports state 
that a PSC completed a certain number of data requests, without any 
additional information.  In other monthly reports, other PSCs list only the 
titles of the data analysis projects.   
PSCs also differ as to what they consider to be a data analysis project.  Some 
PSCs include preliminary data analysis projects in their monthly status 
reports, whereas other PSCs list only projects for which they have already 
completed the preliminary data analysis and which they consider viable 
fraud cases.  Further, some PSCs have not only listed new data analysis 
projects in their reports, but have also listed ongoing ones.  This may explain 
the range in the number of unique data analysis projects performed by PSCs 
each month.      
Because of these limitations in the monthly status reports, we did not attempt 
to correlate the number of unique data analysis projects to the number of 
Medicare and/or Medicaid referrals or to the amount of expenditures avoided 
or recouped. 
PSCs, State Medicaid program integrity agencies, and Medi-Medi partners 
may not always agree as to which of them initiated a referral for fraud, 
waste, or abuse, or which of them was responsible for expenditures that were 
avoided or recouped.35  To minimize the time burden on the State Medicaid 
program integrity agencies and the Medi-Medi partners, we limited their 
 
35
 This statement is based on responses given during our structured interviews with PSCs and State Medicaid 
program integrity agencies.    
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  12  involvement to structured interviews and did not ask them to verify CMSs 
reported output. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  13  FINDINGS 
Although most PSCs performed all of the required 
tasks, the Medi-Medi program produced limited results 
and few fraud referrals  
For the period of 2007 and 2008, 7 of the 10 PSCs performed all of the 
required SOW tasks while each of the remaining 3 PSCs performed all but 
1 of the required tasks.  See Appendix C for our analysis of PSCs 
performance of SOW tasks in 2007 and 2008. 
 
Three of the PSCs did not develop and refer potential fraud 
cases during 1 of the 2 years of the review period 
The SOW states that fraud cases shall be developed and further states 
that the PSC shall refer potential fraud cases and/or data leads to the 
appropriate State or Federal law enforcement agency....  Of the three 
PSCs that did not perform all of the required tasks, all did not develop and 
refer potential fraud cases in 1 of the 2 years of our review period.  Two of 
those three PSCs did not refer any potential Medicare or Medicaid fraud 
cases in 2007.  The remaining PSC did not refer any potential cases 
through the program in 2008.   
A total of $60 million was appropriated for the Medi-Medi 
program, and $57.8 million in expenditures were avoided and 
recouped 
The DRA appropriated funding for the Medi-Medi program on an 
FY basis.  According to CMS Medicare program integrity staff, the actual 
combined total of fraud, waste, and abuse expenditures avoided or 
recouped through the Medi-Medi program during that period was 
$57.8 million (see Table 1).   
 
 
Table 1:  Combined Totals of 2007 and 2008 Expenditures Avoided and Recouped 
 
Program  Expenditures Avoided   Expenditures Recouped  Total 
 
Medicare  $11,593,283  $34,934,559  $46,527,842 
Med icaid  Not reported36  $11,303,554  $11,303,554 
Tota ls  $11,593,283  $46,238,113  $57,831,396 
Sourc e:  OIG analysis of Medi-Medi data. 
 
 
36
 During 2007 and 2008, CMS did not collect data from PSCs regarding the amount of Medicaid expenditures 
avoided through the Medi-Medi program. 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  14  Of the fraud, waste, and abuse expenditures avoided or 
recouped, 66 percent was attributed to Medi-Medi activities in 
three States 
Of the combined $57.8 million in fraud, waste, and abuse expenditures 
avoided or recouped through the Medi-Medi program, a combined total of 
$37.9 million was attributed to Medi-Medi activities in three States; 
individual totals were $14.5 million, $14.3 million, and $9.2 million, 
respectively37 (see Table 2).38 
Ta ble 2:  Combined 2007 and 2008 Medicare Expenditures Avoided and   
Recouped and Medicaid Expenditures Recouped by Each Medi-Medi Program 
 
Medi-Medi Program   Expenditures Avoided  Expenditures Recouped  Total 
1   $8,849,636  $5,666,021  $14,515,657 
2  $0  $14,250,957  $14,250,957 
3  $364,909  $8,799,834  $9,164,743 
4   $991,901  $3,877,993  $4,869,894 
5  $0  $4,490,955  $4,490,955 
6  $370,499  $3,654,965  $4,025,464 
7   $0  $3,000,191  $3,000,191 
8  $895,617  $1,285,350  $2,180,967 
9  $104,468  $1,211,847  $1,316,315 
 
10  $16,253  $0  $16,253 
Total   $11,593,283  $46,238,113  $57,831,396 
 
Source:  OIG analysis of Medi-Medi data.   
 
Expenditures avoided.  CMS reported that, as a result of the Medi-Medi 
program, a total of $11.6 million in Medicare expenditures was avoided 
through prepayment denials during the period of 2007 and 2008.  However, 
of this amount, $8.8 million (76 percent) was attributed to Medi-Medi 
activities in one State. 
Expenditures recouped.  During the same period, a total of $46.2 million in 
Medicare and Medicaid expenditures was recouped through the Medi-Medi 
program.  However, of this amount, $28.7 million (62 percent) was 
attributed to the same three Medi-Medi programs that recouped and avoided 
$14.5 million, $14.3 million, and $9.2 million, respectively, in total 
Medicare and Medicaid expenditures.   
The Medi-Medi program produced only 66 law enforcement 
referrals; 27 were accepted 
During 2007 and 2008, a combined total of 66 Medicare and Medicaid 
referrals were made to Federal and State law enforcement through the 
 
37
 Because of rounding, the sum of these figures does not equal $37.9 million. 
38
 The Medi-Medi programs in Table 2 are ranked by the total amount of Medicare and Medicaid expenditures  
reported as having been avoided or recouped.   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  15  Medi-Medi program, and law enforcement accepted 27 of these (see 
Table 3). 
 
Table 3:  Combined 2007 and 2008 Medi-Medi Law Enforcement Referrals 
  Number Referred to   Number Accepted  Percentage Accepted 
Program  by  
Law Enforcement  by Law Enforcement 
Law Enforcement 
 
Medicare  56  23  41% 
 Medicaid  10  4  40% 
Totals  66  27  41% 
   
Source:  OIG analysis of Medi-Medi data.
 
As a result of Medi-Medi activities among the 10 States collectively, each 
State averaged 2.8 Medicare referrals to law enforcement per year; an 
average of 1.15 of those referrals were accepted.  In comparison, each State 
averaged 0.5 Medicaid referrals to law enforcement per year; an average of 
0.2 of those were accepted. 
 
Medi-Medi activities in a single State produced 27 of the total referrals 
(41 percent) and 10 of the total accepted referrals (37 percent).  Of the 
Medi-Medi activities in the 10 States, 41 percent of the total referrals and 
37 percent of the accepted referrals were attributed to Medi-Medi 
activities in a single State (see Table 4).  This is the same State that 
recouped $14.3 million total Medicare and Medicaid expenditures during 
2007 and 2008. 
 
Table 4:  Combined 2007 and 2008 Medi-Medi Law Enforcement Referrals 
 
Referred to   Accepted by  
Medi-Medi Program 
Law Enforcement  Law Enforcement 
 
1  27  10 
 
2  8  2 
3  7  5 
 4  6  3 
5  6  1 
 6  4  3 
7  4  1 
 8  2  1 
9  1  1 
 10  1  0 
Total   66  27 
 
 
Source:  OIG analysis of Medi-Medi data.  
 
Results from the Medi-Medi program improved slightly between 
2007 and 2008 
Between 2007 and 2008, the amount of Medicare expenditures avoided 
through the Medi-Medi program increased by $1.1 million and the amount 
of Medicare expenditures recouped increased by $10 million.  During the 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  16  same period, Medicaid expenditures recouped increased by $4.4 million.  
In addition, the total number of Medicare and Medicaid referrals made to 
Federal and State law enforcement increased by 18, while the number of 
those referrals accepted increased by 5. 
 
State Medicaid programs received less benefit from 
the Medi-Medi program than Medicare received 
Compared with Medicare, Medicaid received less benefit from the        
Medi-Medi program.  Of the $46.2 million total in Medicare and Medicaid 
expenditures recouped through the Medi-Medi program during 2007 and 
2008, more than three-quarters$34.9 millionwas recouped for Medicare 
and $11.3 million was recouped for Medicaid.  Between 2007 and 2008, the 
amount of Medicare expenditures recouped increased by $10 million, while 
the amount recouped for Medicaid increased by $4.4 million.  During the 
same period, of the 66 law enforcement referrals made, more than           
five-sixths56 of the referralswere for Medicare and 10 were for 
Medicaid.  Law enforcement accepted 23 of the Medicare referrals and only 
4 of the Medicaid referrals.   
 
Although Medi-Medi appropriations were intended to expand the 
program, no new States were participating as of 2008 and two of 
the participating States ultimately withdrew 
The DRA provisions were intended to establish and fund an expanded  
Medi-Medi program.  However, during the period of our review, only 
10 States had chosen to participate.  Of those 10 States, 2 States withdrew, 
finding that it offered them minimal expenditure avoidance and recoupment 
of Medicaid funds.39  State participation in the program is voluntary, and 
States must contribute their own resources to participate.  One of the two 
States that withdrew reported that it invested $250,000 of its own resources 
in the program, but recouped only $2,000 over a 5-year period (which 
included 2007 and 2008).  However, during 2007 and 2008, that State also 
administered its own Medicaid integrity program independent of the 
Medi-Medi program, and this independent program recouped $28.9 million. 
After 2008, 7 additional States joined the Medi-Medi program, resulting in a 
total of 15 participating States.40  As a result of the transition to ZPICs, the 
seven additional States joined the Medi-Medi program as part of three 
geographic areas.41    
 
39
 Of the two States that withdrew, one withdrew in September 2008 and the other withdrew in January 2010.   
40
 Information provided by Medicare program integrity staff.     
41
 Colorado and Oklahoma were included in one ZPIC geographic area.  Arkansas, Georgia, and Mississippi 
were included in a second geographic area, and Iowa and Utah were included in a third geographic area.  
Information provided by Medicare program integrity staff.   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  17  During 2007 and 2008, 54 percent of the funds appropriated for the  
Medi-Medi program were used to develop the One PI System, but 
the system will not include Medicaid claims data until at least 2015 
In total, $60 million was appropriated to fund the Medi-Medi program during 
2007 and 2008.42  Of this amount, 54 percent ($32.5 million) was used to 
develop the One PI System.43  During 2009 and 2010, $108 million in total was 
appropriated to fund the Medi-Medi program, and an even larger percentage of 
those funds64 percent ($69 million)was used to develop the One PI 
System.44  However, according to Medicare program integrity staff and CMS 
One PI staff, the One PI System will not be available for the Medi-Medi 
program until at least 2015, 4 years after its originally scheduled 
implementation date.   
According to CMS Medicare program integrity staff, the lack of appropriate 
Medicaid claims data for CMS to integrate into the integrated data repository 
is the main barrier to using the One PI System for the Medi-Medi program.  
CMS currently collects Medicaid claims data from each State via MSIS.  
According to CMS Medicare program integrity staff, MSIS data in their 
current form would not be appropriate to integrate into the integrated data 
repository because the data are specific to each State and lack many of the 
standardized data elements needed for program integrity work.45  Some 
examples of standardized data elements needed for program integrity work 
but not included in MSIS are provider names and addresses, information 
about types of procedures and services, and beneficiary names.   
 
Limitations in the administration of the Medi-Medi 
program may have diminished its potential 
Lack of inclusion of the Medicaid Program Integrity Group in the 
administration of the Medi-Medi program, limitations of the Fraud 
Investigation Database, and the lack of documentation in CMSs annual 
assessments of PSCs may limit the potential of the Medi-Medi program. 
 
 
42
 Data provided by CMS One PI staff and Medicare program integrity staff.   
43
 Information provided by Medicare program integrity staff.  
44
 Ibid. 
45
 MSIS was designed to collect specific information from each Medicaid agency that would allow CMS to 
report on State Medicaid program characteristics and utilization.  According to CMS Medicare program 
integrity staff, MSIS data were not designed to support fraud analytics and they lack standard data elements 
necessary for that purpose.  Because of a lack of standardization, the data cannot be used for national analysis.  
CMS anticipates that it will eventually be able to integrate Medicaid claims data into the integrated data 
repository by receiving from States data with common data elementsi.e., definitions, formats, and 
representations will not vary by State.   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  18  Federal officials from the CMS Medicare Integrity Group do not 
include Federal officials from the CMS Medicaid Integrity 
Group in administering the Medi-Medi program 
The Medi-Medi program is intended to be a collaborative effort to combat 
Medicare and Medicaid fraud, waste, and abuse.  However, according to 
CMS Medicare program integrity staff and a former Center for Medicaid and 
State Operations official, although Medicaid program integrity agencies are 
involved at the State level, Federal officials from the CMS Medicare 
Integrity Group do not include Federal officials from the Medicaid Integrity 
Group in administering the Medi-Medi program.   
During structured interviews, 5 of the 10 State Medicaid program integrity 
agencies and 3 of the 10 PSCs suggested that CMS include Federal 
officials from the Medicaid Integrity Group.  According to the 
respondents, this would enable CMS Medicare program integrity staff and 
PSCs to better understand the Medicaid side of the program, such as how 
to better interpret and analyze Medicaid claims data.  Four of the 
10 participating State Medicaid program integrity agencies said that PSCs 
do not understand Medicaid and that as a result they primarily analyze 
Medicare claims data. 
 
Access to information in the Fraud Investigation Database is 
limited 
For the purpose of the Medi-Medi program, PSCs are required to enter 
information into the Fraud Investigation Database relating to Medicare, 
Medicaid, and Medi-Medi fraud, waste, and abuse investigations.46  PSCs 
are required to do this in part to make such information available to State 
Medicaid program integrity agencies.47  The database is intended to provide 
State Medicaid program integrity agencies with information about Medicaid, 
Medicare and Medi-Medi investigations.   
Five of the ten participating State Medicaid program integrity agencies 
report they do not use the Fraud Investigation Database because CMS did 
not provide access to it.  An additional four State Medicaid program 
integrity agencies reported they have difficulty accessing the database 
because it is not user-friendly.  The remaining State Medicaid program 
integrity agency reported:  [O]ver the years we have periodically tried to 
use the [Fraud Investigation Database], but found it to be cumbersome and 
of limited use. 
 
46
 CMS, Medicare-Medicaid Data Match Program (Medi-Medi) Policies and Procedures Manual, p. 65.  
47
 CMS, Medicare Program Integrity Manual, Pub. 100-08, ch. 4,  4.11.  Accessed at 
https://www.cms.gov/manuals/downloads/pim83c04.pdf on May 27, 2010.      
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  19   
PSCs do not receive rating scores directly assessing their 
performance of required tasks listed in the Medi-Medi Statement 
of Work 
The Evaluation Guidelines include guidance for assessing performance on 
the six tasks.  However, CMS does not identify each of the required SOW 
tasks in either the Findings Tables or Performance Reports, nor does it 
document its ratings of PSCs on their performance of each SOW task.  
According to CMS Medicare program integrity staff, because the SOW is 
added onto a broader program integrity task order, the majority of the 
content in the Findings Tables and Performance Reports applies to the 
performance under that broader task order.  In addition, content in the 
Findings Tables and Performance Reports assessing PSCs performance 
under the broader program integrity task order is commingled with content 
about their performance under of SOW tasks.  As a result, PSCs do not 
receive rating scores specific to their performance of each SOW task. 
According to CMS Medicare program integrity staff, CMS has never 
made a decision not to renew a PSCs broader program integrity task order 
based solely on a PSCs performance under the SOW.  CMS uses the 
Findings Tables to document assessment findings and ratings and to 
provide verbal feedback to PSCs regarding their performance under the 
SOWs.   
 
 
 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  20  RECOMMENDATION 
The SSA requires that the Medi-Medi program increase the effectiveness and 
efficiency of the Medicare and Medicaid programs through cost avoidance 
(i.e., prepayment denials); savings; and recoupment of fraudulent, wasteful, 
or abusive expenditures.  However, during 2007 and 2008, the Medi-Medi 
program produced limited results and few fraud referrals, and the majority of 
those results were attributed to Medi-Medi activities in three States.  
Compared with Medicare, State Medicaid programs received less benefit 
from the Medi-Medi program.  Limitations in the administration of the 
program may have diminished its potential. 
We recommend that CMS:   
Reevaluate the goals, structure, and operations of the       
Medi-Medi program to determine what aspect of the program, 
if any, should be part of CMSs overall program integrity 
strategy 
As part of this reevaluation, CMS could: 
  Determine how, if at all, the Medi-Medi program could be a more 
effective program integrity resource.   
  Determine whether appropriations for the Medi-Medi program should 
continue to be used to develop and implement the One PI System. 
  Determine whether including officials from the Medicaid Program Integrity 
Group in administering the Medi-Medi program would improve its results.    
  Ensure that each participating State Medicaid program integrity agency has 
appropriate access to useful information in the Fraud Investigation Database.  
As needed, CMS also could provide additional user guidance to State 
Medicaid Program Integrity agencies for using the database. 
  Establish appropriate standards in the SOW to measure PSCs 
performance in relation to the number of fraud referrals and the amount 
of Medicare and Medicaid fraud, waste, and abuse expenditures avoided 
and recouped.   
  Directly assess PSCs performance of each task listed in the SOW, and 
determine whether performing those tasks produces cost-effective results.  
In addition, CMS could assess the benefit of providing PSCs with 
comprehensive written analyses of their performance of each SOW task 
(and any corrective action plans).  
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  21  AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with our recommendation.  CMS commented that since 
the period of our review, it has made significant strides in enhancing the 
effectiveness of the Medi-Medi program and its overall program integrity 
efforts.  CMS further stated that the program has been a useful tool in 
helping fight fraud, waste, and abuse and that the program will become 
more effective over time as more States participate.  However, CMS has 
not provided any data to illustrate enhanced effectiveness of the program 
since the period of our review.  CMS has not provided any data regarding 
the number of referrals, accepted referrals, and the actualnot potential
Medicare and Medicaid expenditures avoided and recouped.   These data 
would enable Congress to make an informed decision whether to continue 
appropriating funding for the program.  These data would also enable 
stakeholders (i.e., CMS, States, and Medi-Medi partners) to make an 
informed decision on whether to use their resources to participate.    
For the full text of CMSs comments, see Appendix D. 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  22  APPENDIX A 
Sources for Centers for Medicare & Medicaid Services Requirements for 
the Medicare-Medicaid Data Match Program 
 
Sources for Requirements  Description 
 
  Identifies Program Safeguard Contractors (PSC) program integrity 
Medicare Program Integrity Manual  requirements, such as the requirement to enter data into the Fraud 
Investigation Database. 
 
 
The Medicare-Medicaid Data Match Program  Identifies the tasks that PSCs were required to perform for the    
(Medi-Medi) Statement of Work (SOW)  period of 2007 and 2008. 
 
 
Provides Medi-Medi program guidance to PSCs, State Medicaid 
The Medicare-Medicaid Data Match Program 
(Medi-Me di) Policies and Procedures Manual  program integrity agencies, and Federal and State law      
enforcement agencies.     
 
  Sets forth the Medi-Medi SOW performance requirements and 
PSC Performance Evaluation Guidelines 
provides guidance for assessing PSCs performance. 
 
  Identifies the key elements and review methodology for assessing 
PSC BI [Benefit Integrity] Evaluation Control 
PSC performance, as well as the corresponding written assessment 
Objectives and Findings Tables 
and rating. 
 
 
   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  23  APPENDIX B 
Required Tasks Listed In the Statement of Work and Documentation 
Analyzed To Determine Whether the Task Was Performed 
A shaded background indicates that Program Safeguard Contractors (PSC) 
were not required to perform the task during the period of our review.  
Only one PSC was required to perform transition activities (Task #10). 
Medicare-Medicaid Data Match Program Tasks and Documentation and Data Analyzed 
Statement of Work (SOW) Tasks  Documentation and Data Analyzed 
1.  Incorporate a project plan.    This Medicare-Medicaid Data Match Program (Medi-Medi program)  
SOW task was required to be performed prior to 2007.  Therefore, we did  
not include this task in our analysis.   
2.  Incorporate an information technology plan.   This Medi-Medi SOW task was required to be performed prior to 2007.  
Therefore, we did not include this task in our analysis.   
3.   Submit to Centers for Medicare &  Monthly status reports 
Medicaid Services (CMS) a monthly status 
report. 
Questionnaire responses from CMS Medicare program integrity staff  
Structured interviews with CMS Medicare program integrity staff PSCs  
PSC BI [Benefit Integrity] Evaluation Control Objectives and Findings     
Tables (Findings Tables) 
Standard Contractor Performance Report (Performance Report) 
 
continued on next page
   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  24  APPENDIX B (continued) 
 
Medi-Medi Program Tasks and Documentation and Data Analyzed (continued) 
 
SOW Tasks  Documentation and Data Analyzed 
 
 
4. Develop a joint operating agreement.  Joint operating agreement 
 
Questionnaire responses from CMS Medicare program integrity staff 
 
 
Structured interviews with CMS Medicare program integrity staff and  
PSCs   
 
 
Findings Tables  
 
  Performance Reports  
 
5.  Provide remote user access and support.    Structured interviews with CMS Medicare program integrity staff, PSCs, 
  and State Medicaid program integrity agencies   
 
 
Findings Tables  
 
 
Performance Reports   
 
 
6.   Perform data analysis.  Monthly status reports  
 
 
Structured interviews (with CMS Medicare program integrity staff, PSCs, 
 
and State Medicaid program integrity agencies)   
 
 
Findings Tables  
 
 
Performance Reports   
 
 
 
continued on next page
 
 
 
 
   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  25  APPENDIX B (continued) 
Medi-Medi Program Tasks and Documentation and Data Analyzed (continued) 
SOW tasks  Documentation and Data Analyzed 
7.  Develop and refer potential fraud cases.   Monthly status reports  
Structured interviews with CMS Medicare program integrity staff, PSCs, 
State Medicaid program integrity agencies, and Medi-Medi Partners 
Questionnaire responses from CMS Medicare program integrity staff 
Findings Tables 
Performance Reports   
8.  Facilitate a steering committee.    Quarterly steering committee minutes    
Structured interviews with CMS Medicare program integrity staff, PSCs, 
State program integrity agencies, and Medi-Medi partners   
Findings Tables  
Performance Reports   
9.  Prepare lessons learned reports.   This Medi-Medi SOW task was required to be performed prior to 2007.  
Therefore, we did not include this task in our analysis.   
10.  Perform transition activities.  Structured interviews with CMS Medicare program integrity staff and     
PSCs   
Questionnaire responses from CMS Medicare program integrity staff 
Findings Tables 
Performance Reports   
 
   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  26  APPENDIX C 
Analysis Results of Program Safeguard Contractors Performance of 
Selected Tasks in the Statement of Work for the Medicare-Medicaid Data 
Match Program 
Task #3:  Submit to the Centers for Medicare & Medicaid Services [CMS]  
a monthly status report.  Each program safeguard contractor (PSC) 
submitted a monthly status report to CMS.  Although the format of the 
reports varied among PSCs, the reports contained the content required by the 
Statement of Work (SOW), such as information about provider referrals, the 
nature of investigations, data analysis projects, and Medicare and/or 
Medicaid expenditures avoided or recouped.   
Task #4:  Develop a joint operating agreement.  Each PSC developed a joint 
operating agreement with its State Medicaid program integrity agency and 
other applicable agencies to establish guidelines, duties, and shared 
expectations for the Medi-Medi program.  In addition, as suggested by the 
Medicare-Medicaid Data Match Program (Medi-Medi) Policies and 
Procedures Manual, those agreements were revised as necessary in 2007 and 
2008. 
Task #5:  Provide remote user support and access.  For PSCs, State 
Medicaid program integrity agencies, and Medi-Medi partners, each PSC 
provided remote user support and access to matched Medicare and Medicaid 
claims data.  However, in 2007, for Medi-Medi programs in two States, 
those two PSCs were not able to provide access to matched Medicare and 
Medicaid data within 4 months of executing a computer match agreement.  
According to CMS Medicare program integrity staff, the delay was due to 
connectivity issues caused by firewalls to the server.  PSCs provided access 
to the data through a variety of means, including the use of transmission 
level-1 lines (commonly referred to as T-1 lines), file transfer via the 
Internet, data tapes, and/or data disks.  According to PSCs and State 
Medicaid program integrity agencies, user support and access improved in 
those States where PSCs provided staff to work directly onsite with the State 
Medicaid program integrity agency staff.   
Task #6:  Perform data analysis.  Based on our review of the monthly status 
reports, PSC BI [Benefit Integrity] Evaluation Control Objectives and 
Findings Tables, Standard Contractor Performance Report, and structured 
interviews, each PSC performed data analysis.  Each PSC performed at least 
36 total unique data analysis projects during 2007 and 2008.  The number of 
unique projects per PSC ranged from 36 to 677.  In 2007, each PSC 
performed at least 16 unique data analysis projects, and in 2008, each PSC 
performed at least 10 unique projects. 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  27   
APPENDIX C (continued)  
Task #7:  Develop and refer potential fraud cases.  Based on our review of 
the monthly status reports, questionnaire responses from CMS, and 
structured interviews, 7 of the 10 PSCs developed and referred potential 
fraud cases in both 2007 and 2008.  However, among PSCs that did so 
during that time, the number of referrals ranged from 2 PSCs that referred 
4 potential fraud cases each to a PSC that referred 27 fraud cases.  
Task #8:  Facilitate a steering committee.  Each of the PSCs facilitated a 
steering committee with its State Medicaid program integrity agency and 
Medi-Medi partners and prepared minutes from committee meetings.  
However, the Medi-Medi SOW states that the steering committee should 
meet not less frequently than quarterly.  Although PSCs may have 
scheduled quarterly meetings, according to the dates entered on the 
committee minutes, five PSCs may have met less frequently in 2007 and one 
PSC may have met less frequently in 2008.     
Task #10:  Perform transition activities.  Based on responses provided by 
CMS Medicare program integrity staff to our questionnaire, one PSC was 
required to perform transition activities and that PSC performed this task 
by submitting the required information to the Zone Program Integrity 
Contractor that was awarded the SOW. 
 
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  28  APPENDIX D 
Agency Comments 

..
". .... 
~ 
(  DEPARTMENT OF HEALTH &. HUMAN SERVICES  CentCfS lor MedlC8JEI & Medicaid Services 
,,~~ 
Adminis#7"tor 
Washington. OC 20201 
JAN 272012
DATE: 
TO: 	 Daniel R. Levinson 
l)lspector General 
FROM:  "'~T/l"erll1er 
Acting Ad~ator 
SUBJECT:  Office ofInspector General (010) Draft Report: "The Medicare-Medicaid (Medi
Medi) Data Match Program" (OEI-09-08-00370) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the OIG draft report entitled, "The Medicare-Medicaid (Medi-Medi) Data Match 
Program." The purpose ofthis report was to determine whether Program Safeguard. Contractors 
(PSC) performed the required tasks for the Medicare-Medicaid Data Match Program (Medi-Medi 
program) and the extent to which the Medi-Medi program identified fraud, waste, and abuse. 
Since the period ofreview ofthis report (2007 -2008), CMS has made significWl\ strides in 
enhancing the effectiveness of the Medi-Medi program and the Agency's overall program 
integrity efforts_ CMS has established the Center for Program Integrity (CPI) that leads a 
collaborative effort to fight waste, fraud, and abuse in Medicare and Medicaid. Specifically, 
since the formation ofCPI, both the CMS Medicare and Medicaid Integrity Program groups have 
been working collabord!ive[y on the ongoing operation ofthe Medi-Medi program. 
The Medi-Medi program has been a useful tool in helping to fight fraud, waste, and abuse. The 
progranl continues to refer potential fraud referrals to law enforcement, and CMS is examining 
opportunities to share best practices among States that have had successful referrals. Six States 
have been added to the Medi-Medi program for a total of 1 5 panicipating States, and there has 
been strong interest from additional States in participating. CMS continues to work with States 
to identify and collaborate on improvements to the program. 
The CMS has already implemented many ofthe suggestions made by OIG including improving 
access to the Fraud Investigations Database for States and establishing appropriate perfonnance 
standards for PSCs alld Zone P, ogram Integrity Contractors (ZPIC). In addition, Medicaid 
program integrity staffregu[arly collaborates in administrating the Medi-Mcdi program. 
As suggested by OIG, CMS is currently assessing the Medi-Medi program regarding program 
integrity efforts and provides further detail on OIG's suggestions below. 
OEI-09-08-00370  The Medicare-Medicaid (Medi-Medi) Data Match Program  29  APPENDIX D (continued) 
 
 
   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  30  APPENDIX D (continued) 
 
   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  31  ACKNOWLEDGMENTS 
This report was prepared under the direction of Timothy S. Brady, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office.  
Michael Henry served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the San Francisco regional 
office who contributed to the report include Loul Alvarez,  
Christina Lester, and Marcia Wong; central office staff who contributed 
includes Scott Manley and Louise Schoggen.  We also would like to 
acknowledge the contributions by Ann Maxwell of the Chicago regional 
office and Robert A. Vito of the Philadelphia regional office.   
OEI-09-08-00370   The Medicare-Medicaid (Medi-Medi) Data Match Program  32  Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is 
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the 
health and welfare of beneficiaries served by those programs.  This statutory mission is carried out through 
a nationwide network of audits, investigations, and inspections conducted by the following operating 
components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with 
its own audit resources or by overseeing audit work done by others.  Audits examine the performance of 
HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  These assessments help 
reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, 
and the public with timely, useful, and reliable information on significant issues.  These evaluations focus 
on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of 
departmental programs.  To promote impact, OEI reports also present practical recommendations for 
improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and 
misconduct related to HHS programs, operations, and beneficiaries.  With investigators working in all 
50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the 
Department of Justice and other Federal, State, and local law enforcement authorities.  The investigative 
efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support for OIGs internal 
operations.  OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty cases.  In 
connection with these cases, OCIG also negotiates and monitors corporate integrity agreements.  OCIG 
renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement 
authorities.