Reimbursement, Billing, ADRS and Claim Appeals – Changing the Order of Medicare System Edits Affecting Hospice Claims

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The 1996 Health Insurance Portability and Accountability Act (HIPAA) gave the Centers for Medicare and Medicaid Services (CMS) the authority to contract with entities other than Medicare Carriers and Fiscal Intermediaries to perform certain Medicare "program safeguard" activities, such as fraud and abuse detection and prevention. As a result, CMS has implemented a system whereby Program Safeguard Contractors (PSCs) compete for task orders issued by CMS to perform a variety of functions involving Medicare program integrity. There are currently twelve PSCs approved by CMS to compete for the task orders.

From a hospice's perspective, there are four PSCs that are particularly important to become familiar with. Each of the four Regional Home Health and Hospice Intermediaries (RHHIs, the fiscal intermediaries for home health agencies) has a PSC tasked with detecting and preventing Medicare fraud and abuse within that RHHI's workload. The following chart lays out information about the current RHHI and the corresponding PSC responsible for preventing fraud and abuse within the RHHI's workload.

RHHIGeographic
Location
PSCPSC Website
United
Government
Services
(UGS)
AK, AZ, CA, HI,
ID, MI, MN, NJ,
NV, NY, OR,
WA, WI,
American Samoa,
Guam, Northern
Marianas, Puerto
Rico, the Virgin
Islands.
TrustSolutions,
LLC
www.trustsolutionsllc.com
Cahaba
GBA
CO, DE, District
of Columbia, IA,
KS, MD, MS,
MT, NE, ND, PA,
SD, UT, VA, WV,
WY.
Cahaba
Safeguard
Administrators,
LLC
www.csallc.com
Palmetto
GBA
AL, AR, FL, GA,
IL, IN, KY, LA,
MS, NC, NM,
OH, OK, SC, TN,
TX.
TriCenturion 
Associated
Hospital
Service of
Maine
CT, MA, ME,
NH, VT, RI.
Electronic Data
Systems (EDS)
or NE-BISC
www.eds.com

Note that for the New England states, EDS holds a contract with CMS to perform Medicare integrity functions for Part A, Part B, RHHI and Durable Medical Equipment Regional Carriers (DMERC). EDS has established what it calls the New England Benefit Integrity Support Center (NE-BISC) to perform these functions. Thus, the PSC may either identify itself as EDS or the NE-BISC, but in either case EDS is the private entity responsible for fraud and abuse detection and prevention in these six states.

Should any of these PSCs contact you requesting information about billing, claims, or other possible Medicare fraud or abuse issues, we recommend that you consult with your legal counsel immediately. It is possible that the PSC is gathering information for a Medicare fraud or abuse investigation, or that an investigation is being contemplated. PSCs work with federal enforcement agencies such as the Department of Health and Human Services' Office of the Inspector General (OIG), the FBI and the US Department of Justice in building Medicare fraud cases against health care providers. Therefore, any request from a PSC should be treated very carefully.

As task orders may expire and again be put up for competition by CMS, the PSC responsible for fraud or abuse detection and prevention for each RHHI workload may change. For this reason, if you are contacted by any of the PSCs you should contact your legal counsel. For your information, the twelve PSCs currently eligible to compete for task orders are:

  • AdvanceMed
  • Aspen Systems Corporation
  • Cahaba Safeguard Administrators, LLC
  • IntegriGuard, LLC
  • Computer Sciences Corporation (CSC)
  • Electronic Data Systems (EDS)
  • Lifecare Management Partners
  • Mutual of Omaha Insurance Co.
  • Reliance Safeguard Solutions, Inc.
  • Science Applications International, Inc. (SAIC)
  • TriCenturion
  • TrustSolutions, LLC

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