Audit Medicare Claims

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I found five agencies that audit Medicare claims, four agencies that audit Medicaid claims, and one agency that regulates both. HEAT (Health Care Fraud Prevention and Enforcement Action Team) audits both Medicare and Medicaid claims. This program tries to prevent fraud and abuse by finding fraud perpetrators and individuals abusing the system. They also focus on protecting Medicare and Medicaid beneficiaries by focusing on the perpetrators that target them. Other agencies that audit Medicare include CMS CERT (Comprehensive Error Rate Testing), MACs (Medicare Administrative Contractors), RACs (Recovery Audit Contractors), and ZPICs (Zone Program Integrity Contractors). CMS using CERT was created in response to the Improper Payments Elimination …show more content…

MACs are responsible for doing prepayment medical reviews on Medicare claims to make sure that the services are medically necessary and that the beneficiary has coverage. RACs use data mining activities to look for Medicare claims that may have been improperly overpaid or underpaid. ZPICs use medical review, evidence-based policies, and data analysis to identify possible abuse, fraud, and waste in Medicare claims. Agencies that focus on Medicaid claims include MICs(Medicaid Integrity Contractors), Medicaid RAC (Medicaid Recovery Audit Contractors), MFCU (Medicaid Fraud Control Unit), OMIGs (State Offices of Medicaid Inspector General), and PERM (Payment Error Rate Measurement). MICs work with the Medicaid Integrity Program of the Social Security Act to audit claims for over payment. They also provide education to providers on payment integrity. Medicaid RACs look for over-payment and underpayment of Medicaid claims and report possible instances of fraud and criminal activity. The MFCU is certified by the secretary of HHS and conduct state initiative to investigate and prosecute providers who have defrauded the Medicaid claims system. OMIGs work within each state to improve the state Medicaid program integrity and help coordinate fraud and abuse activities that span

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