Project Background
On October 1, 2002 the Centers for Medicare & Medicaid Services (CMS) awarded a new contract to SafeGuard Services, LLC (SGS) to establish the Eastern Benefit Integrity Support Center (EA-BISC). This project is part of the CMS Medicare Integrity Program to engage new Program Safeguard Contractors to address Medicare fraud, waste and abuse for specific programs within the states of Connecticut, New York, and New Jersey. SGS will begin this work effective January 15, 2003.
The EA-BISC does not replace the Medicare program administration work that is performed by contractors in the states noted. The current Fiscal Intermediary (Part A) and Carriers (Part B) include National Government Services, HealthNow and Group Health Incorporated (GHI). These Affiliated Contractors (ACs) continue their current responsibilities including medical necessity; and auditing facilities for Medicare expenses and reimbursement.
Project Purpose
The EA-BISC will create a new focused resource to detect and deter fraud in the Medicare Part A and Part B programs. The EA-BISC will perform extensive and unique Medicare regional data analysis to identify aberrant Medicare activities in this region. The EA-BISC will develop cases for referral to law enforcement and provide ongoing support of those cases as needed. The EA-BISC will also process complains alleging fraud for Part A in Connecticut and New York as well as Part B fraud complaints in New York and New Jersey. Additional responsibilities shall include coordination of benefit integrity activities in the region, and dissemination of relevant benefit integrity information to the related ACs, providers and beneficiaries.
Expected Outcomes
- Identification of situations of potential fraud, waste and abuse in the Medicare program for case development and referral to law enforcement.
- Timely and accurate resolution of complaints alleging fraud.
- Identification of Medicare program weaknesses, vulnerabilities, and communication of recommendations for corrective actions, including overpayment recovery and provider education.
Questions
Questions may be directed Cathy J. Failor, Benefit Integrity Manager at:
Cathy J. Failor, B.I. Manager
SGS EA-BISC Medicare Team
Mail Stop F-10
225 Grandview Avenue
Camp Hill, PA 17011
Phone: 717 975-4438
Fax: 717 975-4246
SGS EA-BISC Teams and Locations
Complaint Processing, Investigations, and Data Analysis
SGS EA-BISC Medicare Team
Mail Stop F-10
225 Grandview Avenue
Camp Hill, PA 17001
Investigations
SGS EA-BISC Medicare Team
290 Elwood Davis Road, Suite 218
Liverpool, NY 13088
EA-BISC Program Administration
SGS
Mail Stop: A1-2F-70
5400 Legacy Drive
Plano, TX 75024
Definition of Fraud
The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other persons(s).
Examples of Fraud
- Incorrect reporting of diagnoses or procedures to maximize payments.
- Billing for services not furnished and/or supplies not provided. This includes billing Medicare for appointments that the patient failed to keep.
- Billing that appears to be a deliberate application for duplicate payment for the same services or supplies, billing both Medicare and the beneficiary for the same service, or billing both Medicare and another insurer in an attempt to get paid twice.
- Altering claim forms, electronic claim records, medical documentation, etc. to obtain a higher payment amount.
- Soliciting, offering, or receiving a kickback, bribe, or rebate, e.g., paying for a referral of patients in exchange for the ordering of diagnostic tests and other services or medical equipment.
- Unbundling or “exploding” charges.
- Completing Certificates of Medical necessity (CMNs) for patients not personally and professionally known by the provider.
- Billing based on “gang visits,” e.g., a physician visits a nursing home and bills for 20 nursing home visits without furnishing any specific service to individual patients.
- Misrepresentations of dates and descriptions of services furnished or the identity of the beneficiary or the individual who furnished the services.
- Billing non-covered or non-chargeable services as covered items.
- Repeatedly violating the participating agreement, assignment agreement, and the limitation amount.
- Using another person’s Medicare cared to obtain medical care.
- Giving false information about provider ownership in a clinical laboratory.
- Using the adjustment payment process to generate fraudulent payments.
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