Additional Review Programs

Office of Inspector General (OIG)

Since its 1976 establishment, the OIG has been at the forefront of the nation's efforts to fight waste, fraud, and abuse and to improving the efficiency of Medicare, Medicaid and more than 100 other Health & Human Services (HHS) programs. The OIG's mission is to provide objective oversight to promote the economy, efficiency, effectiveness, and integrity of Department of HHS programs as well as the health and welfare of the people they serve.

Primary functions of the OIG:

• Develop and distribute resources to assist the health care industry in its efforts to comply with the nation's fraud and abuse laws.
• Educate the public about fraudulent schemes so they can protect themselves and report suspicious activities.

Report Suspected Fraud & Abuse

To report suspected cases of fraud, waste, or abuse in Federal HHS programs, use our OIG Online form. You may also call, mail, or fax us using the information below.

• Online: Report Fraud, Waste and Abuse
• Phone: 1-800-HHS-TIPS (1-800-447-8477)
• Fax: (800) 223-8164

Quality Improvement Organization (QIO)

The QIO  Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of HHS' National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS' program experience, CMS identifies the core functions of the QIO Program as:

• Improving quality of care for beneficiaries
• Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting
• Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law

Recovery Auditor (RA)

The Medicare fee-for-service (FFS) Recovery Audit Program  identifies and corrects Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states. RAC's review claims on a post-payment basis.

Cotiviti is the recovery auditor for Region 3, which includes the JN A/B MAC for Florida, Puerto Rico, and the U.S. Virgin Islands. See more details in the table below. 

RA Contact Information

Supplemental Medical Review Contractor (SMRC)

CMS contracts with a Supplemental medical review/Specialty contractor (SMRC) to help lower improper payment rates and protect the Medicare Trust Fund. The SMRC conducts nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claims to determine whether claims follow coverage, coding, payment, and billing requirements. The focus of the medical reviews may include vulnerabilities identified CMS data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations, and federal oversight agencies. At the request of CMS, the SMRC may also carry out other special projects to protect the Medicare Trust Fund.

For more details on the SMRC program, contact Noridian Healthcare Solutions at 1-833-860-4133, or visit Noridian Healthcare Solutions’ SMRC website.

Unified Program Integrity Contractors (UPIC)

Health Insurance Portability and Accountability Act (HIPAA) of 1996 included a provision to establish Medicare Integrity Program (MIP). This provision gives CMS specific contracting authority, consistent with Federal Acquisition Regulations to engage special contractors to promote the integrity of the Medicare program.

These specialty contractors, also known as UPICs, bring expertise to develop cases, conduct data analysis, audit, perform medical review and other tasks to detect and deter fraud, waste, and abuse in the Medicare program.

Major responsibilities of the UPICs:

• Identify and deter Medicare fraud and abuse in the areas noted above
• Implementation of administrative actions such as suspensions and revocation against providers who do not adhere to the CMS guidelines
• Develop high-quality fraud cases for referral to the OIG
• Respond to requests for Medicare data and support from law enforcement
• Identify and report program vulnerabilities to CMS
• Refer recommendations to the appropriate entity for a variety of corrective actions including provider education, overpayment recovery, and licensure considerations
• Develop and validate methodologies for the early detection and prevention of fraud schemes and abusive billing to the Medicare program

CMS awarded a contract to SafeGuard Services LLC (SGS) to operate as the UPIC for the southeastern jurisdiction (SE). 

The SE UPIC performs fraud, waste and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed within the Southeastern Jurisdiction, which includes Florida, Puerto Rico, and the US Virgin Islands for the following types of claims:

• Parts A and B
• DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies)
• Home health and hospice; and
• Claims for dually-eligible Medicare and Medicaid recipients

The UPIC does not replace the Medicare program administration work that is performed by the Medicare administrative contractors. As a note, complaints or allegations of suspected fraud or abuse should be reported to the Medicare contractors who process the claims for initial screening. Allegations of suspected fraud and abuse are brought to the attention of the UPIC only after the possibility of errors or misunderstandings are ruled out.

UPIC Contact Information

Note: Our Provider Contact Center can only answer general questions about the various review programs. Please contact the program directly with inquires related to their activities.

References

• Center for Program Integrity
• Medicare Program Integrity Manual, Pub 100-08