Region D Durable Medical Equipment Benefit Integrity Center

The Region D Durable Medical Equipment Benefit Integrity Support Center (DME-BISC) is a Program Safeguard Contractor (PSC) operated by both IntegriGuard, as a subcontractor, and SafeGuard Services, LLC (SGS), the prime contractor for this contract. The contract to operate Region D DME-BISC was awarded by the Centers for Medicare & Medicaid Services (CMS) to SGS and its subcontractor IntegriGuard in September 2005 at the end of a competitive procurement process.

Use the following link to access the DME-BISC Web site for helpful information:
http://www.edssafeguardservices.eds-gov.com/providers/dme/default.asp

What is purpose of the DME-BISC?

The DME-BISC is a focused resource to detect and deter fraud in the Medicare Durable Medical Equipment (DME) program in Region D. Through its work, the DME-BISC:

• Develops administrative solutions, investigations, and cases for referral to law enforcement
• Provides ongoing support for those cases as needed
• Coordinates benefit integrity activities in Region D
• Disseminates relevant benefit integrity information to the related Affiliated Contractor (AC), provides, and beneficiaries
• Performs all medical review functions, including development and revision of DME Local Coverage Determinations (LCD), provider education and training, and review of medical record documentation for claim submission and correct payment
• Serves as Point of Contact (POC) for CMS’ ongoing CERT activities

What activities do SGS and IntegriGuard perform for the DME-BISC?

The DME-BISC performs the medical review and benefit integrity work to correspond with the States and Territories in Region D, as well as coordinates medical review and benefit integrity activities. The DME-BISC developed a Joint Operating Agreement (JOA) with the DMERC/DME MAC responsible for Region D.

IntegriGuard is responsible for all DME-BISC medical review functions, including pre-payment and post-payment claims review, provider education and training, and medical review in support of fraud and abuse cases.

SGS is contracted to perform the fraud investigation activities, beneficiary outreach, and data analysis scope of this work.

Which States and Territories are in Region D?

Region D consists of Alaska, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming as well as the Mariana Islands and American Samoa.

Why did CMS decide to enter into this arrangement?

In accordance with Section 1834(a)(12) of the Social Security Act, CMS entered into contracts in 1992 with four Durable Medical Equipment Regional Carriers (DMERC) to perform all of the DMERC duties associated with processing of claims for Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) under Part B of the Medicare program. These DMERCs process claims based on a Medicare beneficiary’s principal residence by State or Territory. The transition of all medical review and benefit integrity work from the DMERCs to the PSC DMEs was completed on March 1, 2006.

What is a Program Safeguard Contractor (PSC)?

In 1999, CMS developed the PSC program to support the newly created Medicare Integrity Program (MIP). MIP was created as part of the Health Insurance Portability and Accountability act (HIPAA) of 1996. Part of MIP's purpose is to strengthen CMS' ability to deter fraud and abuse in the Medicare Program by giving CMS specific contracting authority, consistent with Federal Acquisition Regulations, to enter into contracts with entities to promote the integrity of the Medicare program. These MIP specialty contractors, or PSCs, can take on some, all, or any subset of the work associated with the following payment safeguard functions:

• Medical review
• Cost report audit
• Data analysis
• Provider education and fraud detection
• Prevention

What activities do DME MACs perform for Region D and where are claims sent?

In accordance with Section 911 of the Medicare Modernization Act (MMA), CMS will award four contracts to DME MACs to perform all of the DME duties associated with the processing of claims for DMEPOS under Part B of the Medicare program. The DME MACs will process claims based on a Medicare beneficiary’s principal residence by State and Territory. PSCs will align with DME MACs by July 1, 2006.

How is CMS ensuring that the contractors and the PSC properly coordinate their activities and respond to provider needs?

The accountability for ensuring that the two contractors coordinate appropriately rests with CMS. Through active involvement in the transition process, CMS ensured that both parties understand their individual and collective roles and responsibilities. In addition, CMS required both contractors to enter into a JOA. This document delineates each contractor's roles and responsibilities, including how each operates and coordinates activities and data between them. CMS monitors both contractors and the JOA throughout the life of both parties' contracts.

Who can I call if I have a problem?

Call 1.800.MEDICARE to request more information or to get a question answered.