services RESOURCES
Quick Reference Resource Guide
To save you time, Proven Healthcare Solutions is pleased to provide you with this quick reference guide to key hospital compliance organizations.

Recovery Audit Contractor (RAC)
The Centers for Medicare & Medicaid Services (CMS) effort to identify improper Medicare payments and fight fraud, waste and abuse in the Medicare program has been started by awarding contracts to four permanent RACs to guard the Medicare Trust Fund. The Tax Relief and Health Care Act of 2006, required a permanent and national RAC program to be in place by January 1, 2010. The national RAC program is the result of a successful demonstration project that used RACs to identify Medicare overpayments and underpayments. The demonstration, performed in four states, resulted in over $900 million in overpayments being returned to the Medicare Trust Fund between 2005 and 2008 and nearly $38 million in underpayments returned to healthcare providers.

The goal of the RAC program is to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments. Overpayments can occur when healthcare providers submit claims that do not meet Medicare's coding or medical necessity policies. Underpayments can occur when healthcare providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed. Healthcare providers that might be reviewed include hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers and any other provider or supplier that bills Medicare Parts A and B.
http://www.cms.hhs.gov/RAC

Highmark Medicare Services
The Part A Medicare Administrative Contractor (MAC) for Delaware (DE), New Jersey (NJ), Pennsylvania (PA), Maryland (MD) and the District of Columbia (DC), and the Part B MAC for Pennsylvania (PA), New Jersey (NJ), Maryland (MD), Delaware (DE) and the District of Columbia Metropolitan Area (DCMA). For Part B services, A/B MAC Jurisdiction 12 includes the Counties of Arlington and Fairfax in Virginia and the City of Alexandria in Virginia. Services for the remainder of the state of Virginia will be covered under A/B MAC Jurisdiction 11.
http://www.highmarkmedicareservices.com

Other Useful Highmark Links:

Frequently Asked Questions and Answers
http://www.highmarkmedicareservices.com/ql-faq.html

What's Hot?
Read at a glance what's new today!
http://www.highmarkmedicareservices.com/hot.html

Local Coverage Determinations
Keep up with the latest changes in Medicare covered services
http://www.highmarkmedicareservices.com/websch/MedPolSearchIndex.do?modify=yes

Comprehensive Error Rate Testing (CERT)
A program developed by the Centers for Medicare & Medicaid Services (CMS) to audit random claims monthly to determine if they have been processed correctly. The CMS contractors then use this information to determine the cause of errors and work to resolve them with the providers.
http://www.highmarkmedicareservices.com/cert/index.html

CERT's Impact on You
A request for medical records from AdvanceMed (the medical record review contractor for CERT) is an alert that one or more of your facility's claims has been selected as part of the monthly random CERT sample. The letter will be sent to your facility's designated representative requesting specific clinical documentation. Your facility needs to have a process in place to address the request so that you are able to comply with the request in a timely manner. No response or sending in only part of the requested documentation will result in a CERT denial and a request of a refund of monies previously paid to your facility. If you have a specific contact that you would like to receive CERT requests please visit https://www.certcdc.com/certportal/pages/

Centers for Medicare & Medicaid Services (CMS)
CMS is a Federal agency within the U.S. Department of Health and Human Services (HHS) that administers the Medicare program. CMS also works in partnership with each State to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and HIPAA standards.
http://www.cms.hhs.gov/

Office of Inspector General (OIG)
The mission of the Office of Inspector General (OIG), is to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries of those programs. OIG's duties are carried out through nationwide audits, investigations, evaluations and other mission-related functions performed by OIG component offices. Each fiscal year (FY) the OIG publishes its Work Plan. This publication outlines the activities that OIG plans to initiate or continue with respect to the programs and operations of HHS for the coming year.
http://oig.hhs.gov/

New Jersey Office of the Medicaid Inspector General (OMIG)
The New Jersey Office of the Medicaid Inspector General (OMIG) was created by statute to improve and preserve the integrity of the New Jersey Medicaid program by conducting and coordinating fraud, waste and abuse control activities for all New Jersey State agencies responsible for services funded by Medicaid.
http://www.state.nj.us/njomig/

State of New Jersey Medicaid (NJMMIS) and Payment Error Rate Measurement (PERM)
This is the primary resource for all NJ Medicaid information and updates, including access to Unisys Provider Services. PERM and YOU - CMS measures the accuracy of Medicaid and SCHIP payments made by States for services rendered to recipients through the PERM program. CMS uses three national contractors: a statistical contractor, to provide support by identifying the claims to be reviewed and calculating each State's error rate. A documentation/database contractor to collect medical policies from the State and medical records from providers and a review contractor, to perform medical and data processing reviews of the selected claims in order to identify any improper payments. If a claim is selected in a sample for a service that you rendered to either a Medicaid or SCHIP recipient you will be contacted for a copy of the medical record(s) to support the medical review of the claim. It is important that providers cooperate by submitting all requested documentation in a timely manner because no response or insufficient documentation will count against the State as an error. If the claim submitted for payment is considered improperly paid for the purposes of the PERM program, CMS will inform Medicaid officials of the improper payment and may seek recovery of payment for this claim.
https://www.njmmis.com

New York State Office of the Medicaid Inspector General (OMIG)
The NY OMIG was established by statute as an independent entity within the New York State Department of Health to improve and preserve the integrity of the Medicaid program by conducting and coordinating fraud, waste and abuse control activities for all State agencies responsible for services funded by Medicaid. To carry out its mission, the NY OMIG conducts and supervises all prevention, detection, audit and investigation efforts and coordinates with multiple NY state agencies. Each year the OMIG publishes its Work Plan. This publication outlines the activities that the OMIG plans to initiate or continue with respect to the programs and operations for the coming year.
http://www.omig.state.ny.us/data/component/option,com_frontpage/Itemid,1/