Midwest Integrity Center

The Midwest Integrity Center (MIC) is the PSC operated by IntegriGuard, LLC and its subcontractor, TRAP Systems. The contract to operate this specific PSC was awarded to IntegriGuard in December 2002 at the end of a competitive procurement process.

Which Medicare providers are in the catchment area of the MIC?

Medicare Part A and Part B providers in the states of Nebraska, Kansas, and Missouri that submit claims for Medicare reimbursement are in the catchment area, or claims jurisdiction, of the MIC. In addition, Part A providers that have selected Mutual of Omaha as their Fiscal Intermediary (all states and territories) have been included since May 1, 2003.

How are providers and beneficiaries impacted?

IntegriGuard performs benefit integrity activities aimed to reduce fraud and abuse in the Medicare program from its office in Omaha, Nebraska. Activities associated with this workload include fraud case development, data analysis, medical review to support fraud and abuse cases, and complaint processing. IntegriGuard and CMS work closely to ensure minimal impact on both beneficiaries and the provider community.

Medicare Part A contractors and Part B carriers conduct claims processing activities and other functions aimed at reducing the Medicare fee-for-service error rate. Under this arrangement, Part A contractors and Part B carriers maintain the traditional provider relations and beneficiary service functions. IntegriGuard contacts providers directly in the event that information is required to carry out its activities. Any such request contains instructions on when, where, and how to respond. Medicare providers and beneficiaries will have minimal impact in relation to their filing of claims.

Why did CMS decide to enter into this arrangement?

This contract arrangement is consistent with CMS' business plan for Medicare fee-for-service claims operations and supports CMS' efforts to improve its oversight of Medicare contractors. Using the PSCs to creatively partner with traditional Medicare contractors is a win-win situation for CMS, the PSC, the Carrier/FI, and Medicare providers and beneficiaries because it allows all parties to focus on their strengths and provide quality services to our Medicare providers and beneficiaries.

What activities does IntegriGuard perform as the PSC?

As the PSC, IntegriGuard is responsible for performing appropriate activities to reduce fraud and abuse in the Medicare Program. These activities may include fraud case development, data analysis, and medical review in support of fraud and abuse cases and complaints development.

What activities does each contractor perform?

The MIC administers the Midwest Integrity Program (MIP) as a PSC for the following:

WPS, BCBS of Arkansas, Wheatlands Administrative Services, and TriSpan Health Services continue to perform both program management (i.e., claims processing, administrative) and program integrity functions aimed at reducing the Medicare fee-for-service error rate (i.e., medical review, Medicare Secondary Payer, Local Medical Review Policy development). IntegriGuard is responsible for performing BI activities to reduce fraud and abuse in the Medicare Program. Below is a listing of the MIP activities CMS expects to be performed by IntegriGuard and BCBS of Arkansas, WPS, Wheatlands Administrative Services, and TriSpan.

MIP Operations

IntegriGuard

Fraud case development
Data analysis
Law enforcement support
Medical review to support fraud and abuse cases
Civil monetary penalties
Fraud prevention/detection education
Fraud complaint processing

WPS, BCBS of Arkansas, Wheatlands Administrative Services, and TriSpan

Medical review to support the identification of payment errors
Education to reduce payment error
Contractor medical director activities
Local medical review policy development
Consent settlement
Clearinghouse activities/customer service
Initial complaint screening
Harkin grantee process and tracking system

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 Joint Operating Agreement (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.