decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Medicare Contractor Role in Fraud Enforcement / Overview
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Article Overview
This article explains the role Medicare contractors play in protecting Medicare trust funds and supporting fraud enforcement. It is aimed at readers who work with Medicare claims, compliance, or program integrity, and it summarizes the contractors’ place in the CMS framework, their general responsibilities, and the related guidance found in CMS’s Program Integrity Manual. The article also notes the involvement of the HHS Office of Inspector General and the broader administrative, civil, and criminal enforcement context.
Why This Topic Matters
Understanding contractor responsibilities helps providers, compliance staff, and auditors see how Medicare fraud concerns may be identified and escalated within the CMS system. It also points readers to the CMS guidance that governs contractor program integrity activities.
What You Will Learn
- How Medicare contractors fit into the CMS claims-payment structure
- The general responsibilities contractors have in protecting Medicare funds
- How suspected fraud concerns are gathered and referred within the Medicare program integrity process
- Where CMS guidance on fraud detection and prevention is located
Who Should Read This
- Medical coders
- Billing staff
- Compliance professionals
- Healthcare administrators
- Fraud and abuse investigators
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