Learn more about our recent work and accomplishments.

Program Integrity Knowledge and Resource Center
Learn about calculating overpayments with the latest CPI training
The new Extrapolation/Estimation eLearning course will help you estimate overpayments

The Extrapolation/Estimation course, intended primarily for statisticians and adjudicators, provides instruction based on the new Program Integrity Manual (PIM) 8.4 (PDF) guidelines and focuses on the methodology for calculating an estimation of overpayment. This training is designed to help you interpret CMS policies and procedures consistently with others doing the same work.

Take the Extrapolation and Estimation eLearning course now.

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CMS Data Analysis and Testimony Contributes to First Fraud Conviction Related to the Federal Health Insurance Marketplace
CMS lends technical expertise to take down fraudster guilty of scamming consumers.

CMS supplied the essential data to help Federal prosecutors convict Express ACA, a Miami based Insurance Brokerage Company, of fraudulently enrolling thousands of unsuspecting consumers in Marketplace health insurance plans that they didn’t want or need. The FBI and the Department of Health and Human Services’ Office of Inspector General (HHS-OIG) conducted the investigation. CMS’s Center for Consumer Information and Insurance Oversight (CCIIO) and Center for Program Integrity (CPI) assisted law enforcement in uncovering how Express ACA submitted thousands of health insurance applications on behalf of individuals who had no knowledge of the enrollments, and fraudulently qualified them for a 100% federal subsidy of the policies’ premiums. Expert testimony by CMS staff explained the harmful impact of the fraud on the Marketplace and consumers. This work is part of our commitment to protect taxpayer dollars.

“Our collaboration with partner agencies continues as new fraud schemes are identified, bad actors investigated, and new cases referred to law enforcement. Where appropriate, CMS takes administrative action to assure that fraudulent behavior is punished and perpetrators are prevented from accessing the FFM,” said Deputy Administrator and CPI Center Director Alec Alexander.

Keaton Copeland, owner of Express ACA, was sentenced to 10 years in federal prison and ordered to pay restitution. For more information, read the entire DOJ press release.

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CMS Takes Action to Protect Providers from Identity Theft
Don’t be held liable for fraud committed at your expense.

The Victimized Provider Project is a CPI initiative to assist providers whose identities have been stolen and fraudulently used to bill Medicare. If not corrected, providers may receive a demand letter for recovery of overpayments, debt referrals to the Department of Treasury, and/or tax forms for funds they never received. CPI is stepping in to help validate and remediate a provider’s claims as an identity theft victim. We want to ensure that no provider is re-victimized through the wrongful assignment of debts.

Learn more about the signs of provider identity theft and what you can do to protect yourself.

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Take Medicare fraud, waste and abuse (FWA) fighting further, through innovation
CMS is looking for innovative program integrity solutions to meet the challenges of the new Medicare landscape.

We live in a more complex world today than we did when the Medicare program was created. As the Medicare program has evolved, so have CMS’ efforts to combat FWA to ensure we “pay it right.” What new solutions can we implement? What does the future of program integrity look like? You tell us!

The Future of Program Integrity RFI (PDF) seeks information on how we can better align our initiatives with the changing health care environment. How can we modernize program integrity strategies for value-based programs, prior authorization for Medicare Fee-For-Service, and improve provider education with innovative solutions?

The Advanced Technology in Program Integrity RFI (PDF) asks: how can we use the latest technology such as artificial intelligence to ensure proper claims payment, reduce provider burden, and maximize efficiency? We want to hear your ideas on technology that could be applied to provider enrollment, electronic health records, and data and analytics systems.

Hear from Administrator Seema Verma on why we’re asking for your help.

Telehealth Fraud Takedown
Federal Health Care Fraud in Northeastern U.S. Takedown
Multi-agency collaboration addresses opioid epidemic and ongoing DME fraud

On Thursday, September 26, 2019, DOJ announced a coordinated health care fraud enforcement action in the northeastern United States, involving more than $800 million and the distribution of over 3.25 million pills of opioids in “pill mill” clinics. This takedown also included the second phase of “Operation Brace Yourself” where DOJ announced charges in that DME fraud case against defendants around the country for their alleged participation in a massive DME telemarketing fraud scheme back on April 9, 2019. CMS implemented five payment suspensions and referred four providers for Medicare revocation due to their opioid-related billings. In April, CMS took administrative action against 130 DME companies that submitted over $1.7 billion in DME claims to the Medicare program.

“We continue to work closely with our law enforcement partners to identify, investigate and eliminate fraud, waste and abuse in the nation’s federal healthcare programs,” said Deputy Administrator and CPI Center Director Alec Alexander. “CMS is committed to protecting vulnerable beneficiaries from exploitation and safeguarding taxpayer dollars.”

For more information, read the DOJ press release.

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Emergency Department Services Comparative Billing Report (CBR)
Our CBR helped to drive down unnecessary spending and helped educate providers on proper coding.

Our program integrity mantra at CMS is “pay it right.” We use many levers to pay it right, including ones that educate and inform providers about how their billing practices compare with their peers.

Comparative Billing Reports (CBRs) compare an individual provider’s billing and/or prescribing practices for a specific billing code, policy group, or service with the billing and/or prescribing practices of that provider’s peers in the same state and/or specialty, and national averages. 

On November 6, 2017, CMS sent CBRs to 7,245 providers with abnormal billing practices for Emergency Department Services (emergency room visits for the evaluation and management of a patient) (CPT® Codes 99281 – 99285).  We chose these services for a CBR because the 2016 Medicare Fee-for-Service Improper Payments Report identified a 12.4% error rate in billing for emergency room visits, meaning that approximately $268 million, in improper, or incorrect, payments were made.   

The result? In May 2019, CMS observed an 11% decline in CPT® Codes 99281-99285  and a 9% ($63.8 million) decline in allowed charges for these codes.  Our CBR helped to drive down unnecessary spending and helped educate providers on proper coding.

For more information on CBRs visit the Comparative Billing Reports page.

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CMS Partners with the Department of Veterans Affairs to Prevent Fraud Waste and Abuse

The U.S. Department of Veterans Affairs (VA) and CMS recently announced the two agencies will compare information on questionable Veteran health care providers in an effort to minimize fraud, waste, and abuse-- both in VA Treatment facilities and through purchased care programs in their communities. Through the use of CMS protocols, the VA will be provided with a proven tool to use data to address potential problems earlier and more systematically, allowing the VA to take swift action to protect Veterans.

For more information, read the entire press release.

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Operation Double Helix takes action in one of the largest health care fraud schemes ever charged
Fraudulent genetic testing targeted elderly, disabled, and other vulnerable beneficiaries.

Operation Double Helix, spearheaded by the Department of Justice (DOJ) together with the Department of Health and Human Services Office of the Inspector General (HHS-OIG) and the FBI, uncovered an alleged genetic testing scheme valued at over $1.7 billion in fraudulent Medicare claims. The scheme alleges that CGx laboratories paid illegal kickbacks to telemedicine companies and practitioners in exchange for expensive cancer genetic test referrals for people on Medicare. Often, the Medicare patients never received their test results, the results were worthless to their doctors, and the tests were not medically necessary.

As part of this coordinated effort, the Center for Program Integrity (CPI) has taken adverse administrative action against the companies and medical professionals responsible. CMS Administrator Seema Verma said, “In order to prevent additional financial losses, CMS has taken swift action to protect the Medicare Trust Funds from the providers who allegedly have fraudulently billed over $1.7 billion. CMS continues to use a comprehensive and aggressive program integrity approach that includes fraud prevention, claims review, beneficiary education, and targeting high-risk areas of the federal healthcare programs with new tools and innovative demonstrations.”

For more information, read the entire DOJ press release.

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Appalachian Region Prescription Opioid (ARPO) Strikeforce Strikes Again
Second take-down targets opioid “pill mills”

This week, the Justice Department (DOJ) announced another significant law enforcement action by the ARPO strikeforce, with 13 individuals charged – including 11 physicians – in a coordinated effort between DOJ, US Attorney’s Offices, the FBI, Drug Enforcement Agency (DEA), and Health and Human Services Office of Inspector General (HHS OIG). In coordination with this effort, CMS’ Center for Program Integrity announced that all appropriate administrative actions would be taken based on these charges.

“We said in April that the ARPO strike force was not a one-and-done spectacle, but an enduring commitment to stamp out opioid trafficking by prescription pad. We meant it,” said U.S. Attorney Benjamin C. Glassman of the Southern District of Ohio.

The Fraud Section leads the ARPO Strike Force. Since its inception in October 2018, the ARPO Strike Force, which operates in 10 districts, has charged more than 70 defendants who are collectively responsible for distributing more than 40 million pills.

Read the full DOJ press release, here.

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Protecting Medicare Against Fraud and Abuse
Even with new Medicare ID numbers, CMS reminds people to “Guard Your Card!”

CMS continues to take important steps to protect the Medicare program, and people with Medicare, from fraud and abuse. Last year CMS made Medicare cards safer by removing Social Security numbers and replacing them with new, more secure Medicare ID numbers. But despite our efforts, the annual Medicare open enrollment period presents opportunities for fraudsters to take advantage of Medicare beneficiaries. This year, we’ve launched a new ad campaign reminding people with Medicare to continue to “Guard Your Card.”

If you suspect Medicare fraud, waste, or abuse, find out how to report it on our Reporting Fraud page.

For more information, please see the press release.

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CMS takes action to keep fraudsters out of Medicare and Medicaid
The closure of a longstanding loophole will prevent repeat offenders from threatening valuable resources.

CMS issued a first-of-its-kind final rule with comment—Medicare, Medicaid, and Children's Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC)—that strengthens the agency’s ability to stop fraud before it happens by keeping unscrupulous providers out of our federal health insurance programs. Importantly, the new affiliations authority in the rule allows CMS to identify individuals and organizations that pose an undue risk of fraud, waste or abuse based on their relationships with other previously sanctioned entities. Additionally, CMS can now block providers and suppliers who are revoked from re-entering the Medicare program for up to 10 years. Previously, revoked providers could only be prevented from re-enrolling for up to 3 years.

These important new authorities and restrictions, which go into effect on November 4, 2019, ensure that the only providers and suppliers that will face additional burdens are “bad actors” — those who have real and demonstrable histories of conduct and relationships that pose undue risk to taxpayers and beneficiaries. This new rule ushers in an important new era of smart, effective, proactive and risk-based tools designed to protect the integrity of these vitally important federal healthcare programs we rely on every day to care for millions of Americans.

Read the final rule with comment .


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Page Last Modified:
03/27/2020 01:15 PM