Confused by the Medicare audit and fraud programs?

Are you confused by the different Medicare audit and fraud programs? Do you know the difference between a RAC, a SMRCs and a ZPIC? If not, you are not alone! Over the next several weeks the Advocacy Council will publish a series of three articles that will shine a light on this complicated area. We will also tell you how the Centers for Medicare and Medicaid Services (CMS) is trying to simplify things for providers and target improper payments.

We recently attended a meeting at which staff from CMS’ Center for Program Integrity described the audit landscape. CMS estimates that 11% of all Medicare fee-for-service payments are improper. This translates into $41 billion overall. Of that amount, $26.4 billion relates to Medicare Part A providers (e.g. hospitals, skilled nursing facilities); $10.9 billion relates to Part B providers including physicians; and another $3.7 billion is tied to durable medical equipment and supplies.

There are five main types of contractors that you, as an allergist, may encounter should you be the target of one of CMS’ program integrity initiatives. We have heard about allergy services being audited; it is important you be aware of how the basic process works.  The chart below should help you understand what they are and what they do.

Contractor NameClaim SelectionPurpose
Comprehensive Error Rate Testing (CERT)RandomMeasure incidence of improper payments
Supplemental Medical Review Contractor (SMRC)TargetedPost-payment reviews to support special topics identified by CMS or Office of Inspector General
Medicare Administrative Contractors (MACs)Beginning fall of 2017: targeted pre-payment reviewEducation and prevention of future improper payments
Recovery Audit Contractors (RACs)TargetedDetect and correct past improper payment
Zone Provider Integrity Contractors (ZPICs)/Unified Program Integrity Contractors (UPICs)TargetedTo identify potential fraud


There is an interactive map available which identifies the specific contractor in each category (except the CERT contractors) for a given state.

CMS is engaged in a number of efforts to simplify the audit process. One focuses on documentation requirements. CMS is seeking input from physicians and other stakeholders as to how to simplify documentation requirements. An email address for submission of suggestions will be made available later this fall.

Another initiative is to improve EHR interoperability by allowing for electronic submission of orders between physicians and secondary providers and suppliers.  CMS also plans to hold quarterly phone-based listening sessions. We will be monitoring these activities and will let you know of opportunities to provide input to CMS.

Future articles in this series will describe new CMS initiatives focused on provider education rather than punishment and will let you know the latest on the RACs.

Advocacy Issue: 
Billing, Coding & Payments