In early 1999, CMRI, the Medicare Quality Improvement Organization (QIO) for California, formed a new, national division dedicated to protecting the Medicare Trust Fund from fraud and abuse: IntegriGuard. In May of that year, IntegriGuard was one of 13 companies awarded a Program Safeguard Contractor (PSC) contract under the new Medicare Integrity Program. There are now 12 PSCs.
In winning this designation, IntegriGuard became eligible to bid on federal task orders for detection and prevention of healthcare fraud and abuse. Our first PSC contract - a $2.5 million task order to conduct medical review throughout the country - was awarded in November 1999, a few short months after becoming a PSC and under highly competitive bidding circumstances.
IntegriGuard was also awarded a Medicare Managed Care Program Integrity Contract (MMC-PIC) in July 2001 - one of eight companies to receive the contract.
Medicare Integrity Program
Early attempts by existing Medicare contractors to safeguard the Medicare program while still engaging in claims payment had met with limited success. In 1996, the Inspector General’s Office estimated that 14 percent of Medicare payments were made improperly. Congress passed the Health Insurance Portability and Accountability Act (HIPAA, also known as the Kassebaum-Kennedy legislation) of 1996 to help remedy this. The law included a provision to establish stable, long-term funding for program integrity activities, called the Medicare Integrity Program.
The Medicare Integrity Program gave the Centers for Medicare & Medicaid Services (CMS, then called HCFA) the authority to contract with entities to promote the integrity of the Medicare program. These new entities are called Program Safeguard Contractors (PSCs) and Medicare Managed Care Program Integrity Contractors (MMC-PICs).
PSCs
Program Safeguard Contractors (PSCs) supplement the current integrity responsibilities and functions of fiscal intermediaries - companies that process Medicare Part A claims such as billing for hospital visits and skilled nursing - and carriers - companies that process Medicare Part B claims such as billing for home health and visits to doctors’ offices.
The Centers for Medicare & Medicaid Services (CMS) would like PSCs to progressively perform more of the functions that have traditionally been performed by the existing Medicare contractors. Five such functions are:
- Pre-payment and post-payment claims review to identify non-covered, non-medically necessary, and unreasonable services
- Reviews for insurers who are primary to Medicare
- Auditing cost reports submitted by institutional providers to determine if costs are allowable and necessary
- Identification of possible fraud cases that are referred to the Health and Human Services Office of Inspector General (HHS OIG) for investigation
- Conducting provider education and training related to Medicare coverage policies and appropriate billing
After being awarded designation as a PSC, an organization can competitively bid on task orders when released by CMS to address program integrity issues within the Medicare program. IntegriGuard was awarded designation as a PSC in May of 1999.
MMC-PICs
Medicare Managed Care Program Integrity Contractors (MMC-PICs) supplement Regional Office & State Agency integrity responsibilities related to Medicare + Choice Organizations (M+COs), also called Medicare Part C. Like the Program Safeguard Contractor (PSC), MMC-PIC was designed specifically to identify, stop, and prevent fraud, waste, and abuse.
It is the intention of the Centers for Medicare & Medicaid Services (CMS) that services performed under MMC-PIC would include:
- Conducting reviews of CMS’s management and administration oversight of the MMC program
- Reviewing and analyzing State regulatory practices
- Evaluating M+COs marketing operations
- Auditing of financial and medical records including claims, payments and benefit packages
- Evaluating enrollment and encounter data
- Collecting and reviewing matters that may contain evidence of fraud, waste, and abuse
- Compliance testing of internal controls of Health Care Prepayment Plan (HCPP) contracting organizations
After being awarded designation as an MMC-PIC, organizations can competitively bid on task orders released by CMS to specifically address program integrity issues within the MMC program. IntegriGuard was awarded designation as an MMC-PIC in July of 2001.