OMAHA, Neb. – The Centers for Medicare & Medicaid Services (CMS) awarded a contract to SafeGuard Services, LLC (SGS) to operate as the Zone Program Integrity Contractor (ZPIC) for Zone 7 effective February 1, 2009. SGS will continue its partnership with IntegriGuard, LLC as its subcontractor to perform medical record reviews, financial reviews, and education activities as it did as the incumbent PSC.
The award of this contract aligns Medicare program integrity functions with the new Medicare Administrative Contractors as required by the Medicare Modernization Act of 2003. Implementation of the ZPIC will streamline program integrity functions, allowing a single entity to address healthcare fraud and abuse across all claim types.
Since 1997, specialty Medicare contractors known as Program Safeguard Contractors (PSC) were responsible for identifying and investigating fraud and abuse in the Medicare program. Within a state or region, there were several PSCs in operation. Each was responsible for program integrity activities related to specific claim types: Part A; Part B; Durable Medical Equipment Prosthetics and Orthotics (DMEPOS); and Home Health and Hospice. As many as three or more separate PSCs may have been operating in a state or region. Under the ZPIC contracts, program integrity activities related to these claim types will be the responsibility of a single contractor.
ZPIC Zone 7 will be responsible for combating and preventing fraud, waste, and abuse in Florida, Puerto Rico, and the U.S. Virgin Islands for the following types of claims: Parts A and B, DMEPOS, Home Health and Hospice, and Claims for dually-eligible Medicare and Medicaid recipients in Florida.
ZPIC Zone 7 will create a focused resource to detect and deter fraud in the Medicare program. In this capacity, it will develop administrative solutions, investigations, and cases for referral to law enforcement, as well as provide ongoing support to law enforcement as needed. Additional responsibilities include coordination of benefit integrity activities in the region and dissemination of relevant benefit integrity information to other Medicare contractors, healthcare providers, and Medicare recipients. To further optimize its operations, SGS will engage the services of several other subcontractors with specialized experience for various portions of the ZPIC work as well as engage a subcontractor to ensure operational standards are met.
ZPIC Zone 7 does not replace the Medicare program administration work that will be performed by the Medicare Administrative Contactors for Florida, Puerto Rico, and the U.S. Virgin Islands. Their responsibilities include processing and paying claims, performing customer service, reviewing the medical necessity of claims unrelated to suspected fraud and abuse, and auditing facilities for Medicare expenses and reimbursement.
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 ZPIC only after the possibility of errors or misunderstandings are ruled out.