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Eastern Benefit Integrity Support Center (EA-BISC) – Program Safeguard Contractor (GEN)
Posted September 9, 2005
Project Background
On October 17, 2002, the Centers for Medicare & Medicaid Services (CMS) awarded a new contract to EDS to establish the Eastern Benefit Integrity Support Center (EA-BISC). This project is part of the CMS Medicare Integrity Program to engage new Program Safeguard Contractors (PSCs) to address Medicare fraud, waste, and abuse for specific programs within the states of New York and New Jersey effective January 15, 2003. The PSC responsible for the states of Connecticut and Massachusetts is the EDS New England Benefit Integrity Support Center (NE-BISC).
The EA-BISC does not replace the Medicare program administration work that is performed by contractors in the locations noted. The current fiscal intermediary (Part A) and carriers (Part B) include Empire Medicare Services, HealthNow New York Inc. – Upstate Medicare Division (UMD), Group Health Incorporated (GHI), and Riverbend Government Administrators. These affiliated contractors (ACs) continue their current responsibilities, including processing and paying claims, performing customer service, reviewing medical necessity, and auditing facilities for Medicare expenses and reimbursement.
Project Purpose
The EA-BISC is a focused resource to detect and deter fraud in the Medicare Part A and Part B programs. The EA-BISC will perform extensive and unique Medicare regional data analysis to identify aberrant Medicare activities in this region. The EA-BISC will develop cases for referral to law enforcement, and provide ongoing support of those cases as needed. The EA-BISC will also process complaints alleging fraud for Part A and Part B in New York and New Jersey. Additional responsibilities shall include coordination of benefit integrity activities in the region, and dissemination of relevant benefit integrity information to the related ACs, providers, and beneficiaries.
Expected Outcomes
- Identification of situations of potential fraud, waste, and abuse in the Medicare program for case development and referral to law enforcement.
- Timely and accurate resolution of complaints alleging fraud.
- Identification of Medicare program weaknesses, vulnerabilities, and communication of recommendations for corrective actions, including overpayment recovery and provider education.
Questions
Questions may be directed to Maurene Mealy, Benefit Integrity Manager at:
Maurene Mealy, B.I. Manager
EDS EA-BISC Medicare Team
Mail Stop F-10
225 Grandview Avenue
Camp Hill, PA 17011
Phone: 717-975-4445
Fax: 717-975-4246
Email: maurene.mealy@eds.com
EDS EA-BISC Teams and Locations
Complaint Processing, Investigations, and Data Analysis
EDS EA-BISC Medicare Team
Mail Stop F-10
225 Grandview Avenue
Camp Hill, PA 17001
Investigations
EDS EA-BISC Medicare Team
520 Columbia Drive, Suite 206
Johnson City, NY 13790
Investigations
EDS EA-BISC Medicare Team
290 Elwood Davis Road, Suite 218
Liverpool, NY 13088
EA-BISC Program Administration
EDS
Mail Stop: A1-2F-70
5400 Legacy Drive
Plano, TX 75024
Definition of Fraud
Fraud is the intentional deception or misrepresentation that an individual (1) knows to be false or does not believe to be true and (2) makes knowing the deception could result in some unauthorized benefit to himself/herself or some other person.
Medicare Fraud Examples
- Billing for services not rendered
- Misrepresenting the diagnosis to justify higher payments
- Falsifying certificates of medical necessity, plans of care, or other records
- Soliciting, offering, or receiving kickbacks
- Unbundling or "exploding" of services to increase reimbursement
- Upcoding (i.e., billing for a higher procedure code than the actual service provided)
- Submitting duplicate claims for reimbursement
- False or misleading cost report entries
Definition of Abuse
Abuse involves incidents or practices that are inconsistent with accepted sound medical, business, or fiscal practices. These actions may result in unnecessary program costs and improper payment for services not meeting professionally recognized standards of care or medical necessity.
Medicare Abuse Examples
- Excessive or unnecessary services
- Breach of assignment agreement
- Routine waiver of coinsurance and deductibles
- Failure to maintain adequate records
- Improper or sloppy billing practices
- Billing Medicare patients at a higher rate than non-Medicare patients
- Submitting bills to Medicare instead of a primary payer
How Do We Develop Cases?
Cases are generated and developed from a number of sources. They come from tips and complaints from providers, beneficiaries, employees, vendors, and other sources. Internal controls such as pre- and postpayment reviews of claims submitted for Medicare reimbursement and the review of the utilization practices of certain services, which are billed to the Medicare program, also serve as sources of information. We have also developed an extensive array of data technology tools to monitor and analyze the multitude of claims we process to detect aberrant practices among all specialties.
Our strongest weapon against Medicare fraud is the telephone.
Report suspicious activities by calling:
Office of Inspector General's Hotline:
1-800-HHS-TIPS
(1-800-447-8477) |
You can also write to the following address:
Upstate Medicare Division
PO Box 5200
Binghamton, NY 13902-5200 |
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