CMS’ Center for Program Integrity (CPI) mission is to protect the Medicare & Medicaid Trust funds against losses from fraud and abuse and other improper payments, and to improve the integrity of the health care system. To achieve this mission, CPI identifies 4 program areas: prevention, detection, recovery and transparency, and accountability:
- Prevention activities include payment system operation, medical review and provider and beneficiary education. CPI plans to expand these activities with improved fraud identification, safeguards, payment system accuracy and coordination with law enforcement.
- Detection activities include plans to implement analytical pilots to detect improper payment trends, such as using provider/supplier enrollment risk-based predictive modeling and geographic mapping based on hotline tips.
- Recovery activities include collaboration with program integrity partners (e.g., OIG, DOJ, state survey and certification agencies, state Medicaid agencies, etc.) to increase overpayment recoveries through restitution, fines, penalties, damages, program suspensions and exclusions.
- Transparency and Accountability activities include plans to develop performance measures used to evaluate outcomes and better track, report and disseminate program integrity information.
Within those 4 areas, CPI also identifies 6 types of integrity activities: provider auditing, medical review, benefit integrity, Medicare secondary payer, provider outreach and education, and Medicare-Medicaid Data Match project:
- Provider activities include desk reviews and field audits. Field audits are designed to ensure compliance with regulations, policies and CMS.
- Medical Review activities are designed to identify and prevent payment errors in billing. Medical review activities also are conducted to ensure that a payment is appropriate for the service that is provided and meets professionally recognized care standards.
- Benefit Integrity includes activities to identify and investigate potential fraud cases and refer these to law enforcement. Benefit integrity activities also include national and regional data analysis to identify aberrant billing patterns, medical documentation review to verify that services were delivered, complaint investigations, and provider/supplier fraud detection and prevention education.
- Medicare Secondary Payer activities ensure that the Medicare program pays only for those services where it has primary payment responsibility. Medicare is prohibited from making payments for any item or service when payment has been made or can reasonably expect to be made by other 3rd party payers.
- Provider Outreach and Education activities include outreach on national and local policies and procedures, new initiatives, significant changes and issues identified through different methods of analysis.
- Medicare-Medicaid Data Match Program is intended to help CMS and the States identify overpayments and fraud that affects both the Medicare and Medicaid programs. Based on comparative Medicare and Medicaid data, CMS investigates atypical billing patterns that may not be evident when analyzing the data from each program separately. If irregularities are found, CMS coordinates with providers (for Medicare) and States (for Medicaid) to recover overpayments.