Fundamentals of Medicare

Section 3: Fraud and Abuse


Program Safeguard Contractor/Zone Program Integrity Contractor

The primary goal of the PSC/ZPIC is to:

  • identify cases of suspected fraud;
  • develop them thoroughly and in a timely manner; and
  • take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid and any mistaken payments are recouped.

National Government Services refers all suspected fraud to the PSC/ZPIC for additional investigation. This may include results found from provider medical review, beneficiary complaints, or through data analysis results. The PSCs/ZPICs responsible for National Government Services investigations are:

  • AdvanceMed
  • Cahaba Safeguard Administrators
  • Safeguard Services

All fraud cases developed by the PSCs/ZPICx are referred to the OIG for consideration and initiation of criminal or civil prosecution, civil monetary penalty, or administrative sanction actions. When the PSC determines that a situation is not fraud, they refer the case back to National Government Services for additional provider education, medical review, or other appropriate action.

Provider Actions to Prevent Fraud and Abuse

Medicare has become big business and has attracted, as big businesses sometimes do, a few unethical individuals/providers. As such, honest health care providers must protect their organization from any potentially inappropriate activities. Use the following suggestions to ensure that you or your provider do not fall victim to potentially fraudulent activities:

  • Stay informed of, and follow Medicare regulations, policies, and guidelines as they relate to the particular type of organization. It has been demonstrated that many inappropriate activities could have been avoided if the provider understood the Medicare regulations that apply to their organization.
  • Ensure that those individuals or entities that are authorized to bill and/or receive payment on behalf of the provider have the appropriate knowledge and expertise to deal with Medicare.
  • Distribute Medicare information and training materials to all staff members and facility contractors who are involved in any of the processes resulting in a service being billed to Medicare. This includes, but is not limited to personnel in administration, registration, clinical areas, clinical support areas, billing, finance, and medical records.
  • Ensure that any document filed with the Medicare Program is accurate and meets the appropriate standards (e.g., claims, medical records, cost reports, applications, etc.).
  • Understand and monitor the terms of employment or contracts to ensure that the provider is not in violation of any law or regulation governing Medicare.
  • Ensure that there are no violations of laws or regulations when conducting business with individuals or entities outside of the provider’s organization.
  • Institute an effective compliance program using OIG guidelines. This is not a Medicare requirement; however, it is an effective safeguard for the provider.

If you suspect any type of fraudulent activity, you should report it to National Government Services through the Provider Contact Center.

The OIG Hotline may also be called at 1-800-HHS-TIPS (1-800-447-8477).

Reviewed 6/4/2024