Program Integrity MEDIC Update

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					Program Integrity MEDIC
        Update
   How does Program Integrity fight fraud,
   waste, & abuse in the Medicare program?



• Parts A, B, & DME are handled by Program
  Safeguard Contractors (PSCs)

• Part C is handled in-house at CMS

• Part D is handled by MEDICs - Medicare Drug
  Integrity Contractors


                                                2
   What are the MEDICs’ duties?

• Answer the 877-7SAFERX Part D fraud, waste,
  & abuse hotline
• Perform data analysis to detect fraud, waste,
  & abuse in Part D
• Investigate accusations of fraud, waste, &
  abuse in Part D

There are a variety of sources for these
  investigations, but the primary sources are the
  telephone hotline and the CTM

                                                    3
   There are currently 3 MEDICs

• West: SAIC
  – Program Director: Judy Olshin
  – By fax: 818-543-7690
  – In writing: SAIC - MEDIC West
             450 North Brand Boulevard, Suite 410
             Glendale, CA 91203
• North: EDS
  – Program Director: Doug Quave
  – By fax: 717-975-4442
  – In writing: EDS - MEDIC North
             225 Grandview Avenue, Mailstop F10
             Camp Hill, PA 17011
                                                    4
   There are currently 3 MEDICs

• Southeast: Delmarva/Health Integrity
  – Program Director: Sandy Love
  – By fax: 410-819-8698
  – In writing: Health Integrity
             Attention: MEDIC
             9240 Centreville Road
             Easton, MD 21601


• The 877-7SAFERX (877-772-3379)
  number works to reach all three MEDICs

                                           5
                               The 3 MEDIC Regions
      WA
                    MT                                                                  VT
                                 ND                                                           ME
 OR                                          MN
                                                                                                        NH
            ID                   SD                 WI                             NY              MA
                     WY                    North: EDS            MI
                                                                               PA                   RI
      NV                          NE          IA                                         NJ    CT
                                                        IL       IN     OH                    DE
             UT          CO
CA                                    KS       MO                         WV VA
       West: SAIC                                                  KY
                                                                 TN                NC
                     NM                OK                             SC                      MD
            AZ                                     AR
                                                         Southeast: Delmarva
                                                        MS AL        GA
                                 TX
                                                   LA
       AK
                                                                              FL
                                                                                              PR



                                 HI                          American Samoa
                                             Guam                                                  USVI
                     Mariana
                     Islands                                                                            6
    Top Medicare Part D FWA Issues


• $299 Scams
• Agent/Broker Misbehavior
• Incorrect Explanation of Benefits
• Drug Seeking/Selling Beneficiaries &
  Over-Prescribing Physicians
• Misleading Marketing and Enrollment
  Information



                                         7
  $299 Scams


• Do not directly affect Medicare Part D
  program from a financial perspective
• Used by criminals to prey on the
  unsuspecting Medicare beneficiary
  population




                                           8
  Agent/Broker Misbehavior

• Misrepresentation that agent works for
  CMS and/or SSA
• Threatening or deliberately misleading
  beneficiaries to sign up for a specific
  plan
• Mass enrolling of LTC residents into plan
  without permission
• Enrollment of dead beneficiaries
• Forged signatures

                                              9
  Incorrect EOB

• List drugs that the beneficiary did not
  purchases
• Drugs are typically high-cost HIV, anti-
  psychotic and cancer medications




                                             10
      DSBs & Over-Prescribers


• Involves:
  –   Forged prescriptions
  –   Stolen Part D identification
  –   Organized drug diversion rings
  –   Script mills




                                       11
  Misleading Marketing & Enrollment
  Information
• Use of incorrect or misleading
  information in:
  – Marketing & Enrollment materials
  – Advertisements




                                       12
 DMMAI Contact


If you need to know about a specific case or if
you have any questions about the MEDIC
program, please contact:

  Stephanie Blaydes Kaisler
  Deputy Director
  Division of MMA Integrity
  Program Integrity Group
  (410) 786-0957
                                                  13

				
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posted:11/30/2011
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