CMS oversees private contractors performing integrity activities, such as provider audits, medical necessity claims reviews and investigations. These contractors develop and refer suspected cases of fraud to the Department of Health and Human Services (HHS), Office of Inspector General (OIG) and Department of Justice (DOJ) for possible investigation or prosecution.
The Affordable Care Act (ACA) also established new tools to fight fraud, including enhanced screenings and enrollment requirements, increased data sharing across the government and expanded recovery efforts for overpayments — many of these tools focus on “prevention” of fraud and abuse. CMS closely coordinates with these contractors to meet their integrity goals.
Learn more about these contractors and their activities:
Difference between RAs, MACs, and ZPICs
ZPICs – there primary mission is to identify fraud – it is not a random audit. There is no specification regarding look back periods and there are unlimited document requests. ZPICS are not paid on a contingency basis but performance bonuses do exist. Because their primary goal is to identify fraud – they will often times refuse to answer specific provider questions.
RAs – the goal is to identify and correct improper payments. They can only look back 3 years and cannot look further back than Oct. 1, 2007. The document requests will vary by provider type and the contingency fee structure is based on recovery.
MACs – the goal is to educate providers and to conduct billing. The MACs correct the behavior in need of change and prevent future inappropriate billing. MACS also recover overpayments.