Sampling for Medicare and Other Claims
Will Yancey, PhD, CPA
Email: wyancey@aclrsbs.com
Office phone 734.744.4400

Dr. Yancey has testified as an independent expert on sampling and projection of Medicare claims and other health insurance claims.


Includes audits of processing of claims, such as Medicare, Medicaid, state-sponsored health care plans, group health care claims, other insurance claims, and government programs.

Disclaimer: Inclusion in this list does not imply the reference is or was a reliable authority or relevant to any particular set of facts.  Omission from this list does not imply the item was not reliable.  Links to consultants does not imply endorsement.

Maintained by ACLR. Please e-mail your suggestions for additions and changes to wyancey@aclrsbs.com.


Sections of this page:


Related Web pages:


Statutory Authority related to sampling Medicare or Medicaid claims

Full text of the U. S. Code is at http://www.law.cornell.edu/uscode/ or http://www.findlaw.com/casecode/uscodes/
Congressional bills and committee reports are at http://thomas.loc.gov/

Regulatory Authority related to sampling Medicare or Medicaid claims


Medicare and Medicaid Payment Reviews - DHHS and CMS Policy

Administrative Authority - US Department of Health and HumanServices

The Centers for Medicare and Medicaid Services (CMS) was formerly known as the Health Care Financing Administration (HCFA). HCFA was renamed CMS in June 2001.
Most of the documents on overpayment audits and sampling are included in Manuals or Program Transmittals.
Program Transmittals are at www.cms.hhs.gov/Transmittals/
Program Manuals are at www.cms.hhs.gov/Manuals/
Acronyms at the www.cms.hhs.gov/apps/acronyms/
News media release database at www.cms.hhs.gov/apps/media/
Press releases at www.cms.hhs.gov/apps/media/press_releases.asp
Fact sheets at www.cms.hhs.gov/apps/media/fact_sheets.asp

Assistant Secretary for Legislation

Health Care Financing Administration (HCFA) Program Manuals, issued and revised prior to June 2001

CMS Program Manuals issued after June 2001

Program Manuals in zipped or PDF format are online at www.cms.hhs.gov/Manuals/
Publications numbered less than 100 are in the Paper Based Manual (PBM) section.
Publications numbered 100 are in the Internet-Only Manual (IOM) section.

Program Transmittals

The Program Transmittals related to sampling are revisions to Medicare Manuals.
Program Transmittals are online at www.cms.hhs.gov/Transmittals/
Selected HCFA and CMS Rulings are posted at http://www.cms.hhs.gov/Rulings/CMSR/list.asp

Open Door Forums ...dialogues between CMS and provider community


Medicare and Medicaid Payment Reviews - DHHS Office of Inspector General (OIG)

OIG home page

Fraud Prevention & Detection

Office of Audit Services (OAS)


Medicaid and State Health Care Programs

The Deficit Reduction Act of 2005 created the Medicaid Integrity Program (MIP) to coordinate national strategy on Medicaid fraud and abuse.

Oversight by Federal, State, and Nongovernmental Organizations and Policy Analysts


Medicare Administrative Contractors (MAC)

Medicare claims processing is provided by Medicare Administrative Contractors (MAC), as authorized by Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173).
CMS awards contracts to the MAC for specific coverage types and geographic areas.
Most MAC have contracts for several coverage types and several geographic areas.
Most MAC are or were affiliated with the 39 member companies of the Blue Cross & Blue Shield Association ("the Blues") or their contractors.
Medicare in the United States is described at http://en.wikipedia.org/wiki/Medicare_%28United_States%29
The Blue Cross & Blue Shield companies are described at http://en.wikipedia.org/wiki/Blue_cross_blue_shield

Medicare Administrative Contractors (MAC) were formerly known as Medicare Carriers and Fiscal Intermediaries.
Carriers made Medicare payments to providers including doctors and equipment suppliers.
Fiscal Intermediaries made Medicare payments to facilities such as hospitals and nursing facilities.
Railroad Retirement Board Carriers (RRBC) administer benefits for railroad retirees.

Medicare Part A Hospital Insurance Intermediaries administer payments to hospitals, skilled nursing facilities (SNF), community mental health centers (CMHC), and other facilities.
Medicare Part A Regional Home Health Intermediaries (RHHI) administer payments to home health agencies.
Medicare Part A Rural Health Clinic Intermediaries (RHCI) administer payments to rural clinics.
Medicare Part B Medical Insurance Carriers administer payments to individual doctors, clinics, and equipment providers.
Medicare Part B Durable Medical Equipment Regional Carriers (DMERC) administers payments to medical equipment suppliers.
Medicare Part C, also known as Medicare+Choice or Medicare Advantage, provide supplements to Parts A and B.
Medicare Part D carriers provide prescription drugs, preventive screenings, and some medical tests.

Recovery Audit Contractors (RAC)

The Recovery Audit Contractor (RAC) demonstration program was authorized by section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173). The program is made permanent by section 302(h) of the Tax Relief and Health Care Act of 2006 (P. L. 109-432).
RACs identify and collect Medical claims overpayments and underpayments that were not previously identified by the MACs.
CMS has contracts with 4 RACs. Each RAC is responsible for identifying overpayments and underpayments in its assigned region.
For more information see https://www.fbo.gov/index and Medicare and Medicaid Payment Reviews - DHHS and CMS Policy

Announcements about RAC program

Contractors for RAC program

RAC contact information.

Advice for providers in RAC audits


Medicare Appeals Process

Medicare providers have a five-step appeals process described at www.hhs.gov/omha/levels/index.html
Regulations for this appeals process are in the Code of Federal Regulations, Title 42, Chapter IV, Part 405, Sections 405.201 through 405.2472.
See the Code of Federal Regulations at http://www.findlaw.com/casecode/cfr.html or http://www.access.gpo.gov/nara/cfr/cfr-table-search.html.
Level 1: After the PSC or ZPIC initial determination, the provider can request a redetermination from a Hearing Officer of the Medicare Administrative Contractor
Level 2: After the MAC redetermination, the provider can request a reconsideration by a designated Qualified Independent Contractor (QIC)
Level 3: After the QIC reconsideration, the provider can request a hearing by an Administrative Law Judge (ALJ) of the Office of Medicare Hearings and Appeals (OMHA)
Level 4: After the ALJ hearing, the provider can request a review by the Medicare Appeals Council of the DHHS Departmental Appeals Board (DAB)
Level 5: After the DAB review, the provider can litigate in federal district court. See Litigation in Federal and State Courts

The Medicare Part C Managed Care appeals process is described at www.cms.hhs.gov/MMCAG/


Medicare Zone Program Integrity Contractors (ZPIC) and Program Safeguard Contractors

The contractors' legal authority was approved by GAO General Counsel Decision B-282777 on September 2, 1999, http://www.gao.gov/decisions/archive/282777.pdf
See the Frequently Asked Questions (FAQs) by CSC.
See the Benefit Integrity commentary by Highmark.
Prior to 2003, the Medicare contractors's own benefit integrity (BI) departments did this type of work. Most benefit integrity functions are now done by other contractors.
In 2002 to 2009, the Program Safeguard Contractors (PSC) conducted Medicare Part A (hospitals, skilled nursing facilities, etc.) and Part B (physicians, labs, therapists, ambulance services, etc.) fraud and overpayment reviews on behalf of the Medicare Administrative Contractors (MAC).
In 2008 and 2009 the PSC contracts are being phased out and replaced with Zone Program Integrity Contractors (ZPIC). Some of the companies that had PSC contracts will have ZPIC contracts. ZPIC contractors will have responsibility for Medicare (Part A, B, DME, Home Health and Hospice) and Medicare Medicaid Data Matching (Medi Medi) Programs.
Each ZPIC contract is expected to run for five years. ZPIC contracts are awarded in three cycles. Cycle 1 for zones 4, 5, and 7. Cycle 2 for zones 1 and 2. Cycle 3 for zones 3 and 6.
For more information see https://www.fbo.gov/index and Medicare and Medicaid Payment Reviews - DHHS and CMS Policy

ZPIC regions

Names of ZPIC and PSC contractors

All of the PSC or ZPIC are or were owned by, affiliated with, have many employees from, or contracted to Medicare administrative contractors.
Some of the companies listed below are no longer serving as a PSC or ZPIC.

Medicare Part D Prescription Drug Integrity Contractor (MEDIC)

Medicare Prescription Drug appeals process is described at www.cms.hhs.gov/MedPrescriptDrugApplGriev/
The Part D appeals process is similar to appeals for Medicare Part A (hospitals) and Part B (phyicians and clinical services) fraud and overpayment reviews.

The national phone number to reach the regional MEDIC programs is (877) 772-3379.
The following companies are or were MEDIC prime contractors or subcontractors.

Qualified Independent Contractors (QIC)

The QIC hear second-level appeals (also known as reconsiderations) from Medicare providers who are disputing the results of the MAC redetermination.
A provider may appeal a QIC decision to an Administrative Law Judge
See the QIC Fact Sheet provided by CMS.

The Centers for Medicare & Medicaid Services (CMS) awarded an Indefinite Delivery/Indefinite Quantity (IDIQ) contracts to seven entities to perform QIC functions. Under this contract, CMS competitively awarded the following task orders:

Administrative Law Judge (ALJ) Hearings

Administrative Law Judges (ALJ) hear appeals of Medicare overpayment reviews.
Prior to 2005 the ALJ who heard these appeals were in the Social Security Administration (SSA) Office of Hearings and Appeals (OHA).
After 2005, Medicare appeals are heard by the DHHS Office of Medicare Hearings and Appeals (OMHA), http://www.hhs.gov/omha/
The OMHA has four regional offices and each hears cases for specific regions as shown at http://www.hhs.gov/omha/about/contacts/offices.html
After the ALJ hearing, the provider may appeal to the Department of Health and Human Services (DHHS) Appeals Board

Regulations for this appeals process are in the Code of Federal Regulations, Title 42, Chapter IV, Part 405, Sections 405.201 through 405.2472.
See the Code of Federal Regulations at http://www.findlaw.com/casecode/cfr.html or http://www.access.gpo.gov/nara/cfr/cfr-table-search.html.

A few ALJ decisions on sampling and extrapolation issues in Medicare overpayment reviews are cited below.
Copies of ALJ decisions may be available after the names and identifying information of beneficiaries have been redacted.

Department of Health and Human Services (DHHS) Appeals Board

Selected Medicare appeals decisions are posted by the Department of Health and Human Servcies (DHHS) Departmental Appeals Board (DAB) at http://www.hhs.gov/dab/macdecision/
Some DAB rulings are searchable at http://www.hhs.gov/dab/search.html
Selected HCFA and CMS Rulings are posted at http://www.cms.hhs.gov/Rulings/CMSR/list.asp
Selected rulings related to statistical sampling and projection are cited below.

Provider Reimbursement Review Board (PRRB)

The PRRB is an independent panel to which a certified Medicare provider of services may appeal if it is dissatisfied with a final determination of its fiscal intermediary or the appeal to CMS.

Litigation in Federal and State Courts

Listed alphabetically by plaintiff's name.

False Claims Act and Qui Tam ("whistleblower claims")

Qui Tam ("He who sues on behalf of the king as well as for himself") is a provision of the Federal Civil False Claims Act (FCA) that allows a private citizen to file a suit in the name of the U.S. Government charging fraud by government contractors and other entities who receive or use government funds, and share in any money recovered. Cases filed under the FCA, 31 US Code sections 3729 ff, often involve sampling from large files of Medicare or other types of claims.  Some of these cases deal with whether statistical evidence is sufficient for proving liability for different types of claims.
See also www.willyancey.com/statistical_evidence.htm#Toxic_Tort

Cases

Articles and Guides

Associations and Law Firms on Qui Tam Litigation and False Claims Act


Health Care Claim Overpayments - Secondary Authority - Articles and Books


Coding Health Care Claims

Coding Reference Sources

Free searches on coding databases

National Provider Identification (NPI) Numbers (PIN)

Coding Consulting Services, Billing Software, and Training


Consultants and Associations on Medicare, Medicaid, and Health Care Bill Auditing

These consultants, associations, and software vendors advise providers, insurers, employers, insureds, or healthcare administrators on claims processing and overpayment reviews. This includes Medicare, Medicaid, other government supported health programs, commercial insurance, and self-insured plans. Inclusion or exclusion on the list below is not a comment on the quality or reputation of the organization.

Contractors to US Department of Health and Human Services are listed at OSDBU Active Contracts


Law Firms Representing Providers in Medicare Overpayment Disputes

Health Law Directories and Associations

Law Firms with a practice area in Health Law

Hundreds of law firms have health law practice groups. Only a few of those firms are listed below.

Publishers, Associations, and Conference Organizers