Name Process Penalties Appeals process
ZPICs
ZPIC audits may be initiated through data analysis
or directly by fraud complaints. ZPIC review of
claims may occur either pre- or postpayment. There
is no limit on document requests for ZPIC audits, in
addition to interviews and on-site visits.
ZPICs refer identified overpayments to their
associated MAC for recoupment or to other state or
federal agencies for other penalties.
ZPICs recoup overpayments and
can refer findings of fraud to
law enforcement for criminal,
civil monetary penalty, or
other administrative sanction
involving the HHS OIG; ZPICs
may also refer such findings to
the U.S. Attorney. ZPICs also
can recommend that their MAC
implements prepayment or
auto-denial edits, if deemed
necessary.
A provider has the right to
appeal ZPIC overpayment
determination through the
five-level Medicare appeals
process by which fee-for-service providers appeal
reimbursement decisions.
MFCUs MFCUs are not restricted to a specific investigational or audit process.
MFCUs recoup overpayments
or refer to an appropriate state
agency for collection, and can
refer a finding of fraud to the
appropriate investigation or
prosecution authority. If there
is a pending Medicaid fraud
investigation, MFCUs may refer
providers to state Medicaid
agency for payment suspension.
The appeal rights of providers
investigated by MFCUs depend
on entity to which the case
is referred for overpayment,
investigation, or prosecution.
CERT
CERT randomly selects a statistical sample of claims
submitted to MACs and requests medical records
from the providers who submitted the claims in
the sample. The claims and associated medical
records are reviewed for compliance with Medicare
coverage, coding, and billing rules.
Errors are assigned to claims in instances of
noncompliance. CMS and CERT contractors analyze
the error rate data and produce a national Medicare
fee-for-service error rate after the review process is
completed.
Claims selected for CERT
review are subject to
overpayment recoupment,
potential postpayment denials,
payment adjustments, or other
administrative or legal actions
depending on the result of the
CERT review.
If a provider fails to submit a
requested record to the CERT
program, the claim counts as
an improper payment and may
be recouped from the provider.
A provider has the right to
appeal CERT determination
through the five-level Medicare
appeals process.
PERM
PERM is conducted over a three-year period,
focusing on 17 states per year. PERM contractors
draw random samples of claims from each state
and request medical records associated with those
claims from the providers, and the medical records
are reviewed to validate compliance with Medicaid
coverage, coding, and billing rules.
The claims determined to have been paid incorrectly
are scored as errors and payments are adjusted
accordingly.
If a provider fails to submit a
requested record to PERM, the
claim counts as an improper
payment and may be recouped
from the provider.
States may pursue two levels
of PERM error determination
dispute: the difference
resolution process and the
CMS appeals process. These
processes afford states the
opportunity to overturn PERM
error determinations.
TABLE 2. PROCESS, PENALTIES, AND APPEALS PROCESS (CONTINUED)
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