decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Medicare_Carriers_Manual / 14003 / 14003.4_DMERC_FRAUD_AND_ABUSE_FUNCTION.-
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Article Overview
This Medicare Carriers Manual article outlines the fraud and abuse function within DMERC operations, including coordination with integrity and review components, handling of regional complaints, use of supplier alert information, and periodic validation studies tied to DMEPOS supplier practices. It is relevant to Medicare program integrity staff, durable medical equipment suppliers, billing professionals, and compliance teams who work with Medicare DMEPOS oversight and fraud prevention processes.
Why This Topic Matters
The article explains how DMERCs are expected to monitor suspicious activity, share information, and review supplier practices in ways that affect program integrity and compliance oversight in the DMEPOS setting.
Article Sections
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Fraud and abuse function within DMERC operations
Describes where the fraud and abuse function is located and how it relates to other Medicare integrity components. It also addresses leadership and organizational separation within the DMERC structure.
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General requirements
Summarizes the broader responsibilities DMERCs are expected to carry out in response to fraud and abuse concerns. The section focuses on coordination, information sharing, and use of supporting data resources.
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Use of National Supplier Clearinghouse (NSC) alert codes
Discusses supplier alert code handling and the need for prompt action when alerts appear in supplier files. The section presents a grouped list of current NSC alert identifiers.
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Certificate of Medical Necessity (CMN) validation
Covers periodic review activities involving CMN-related supplier practices and claim samples. It also describes reporting, record review, and referral-related oversight steps associated with the validation study.
What You Will Learn
- How DMERC fraud and abuse functions are organized within Medicare oversight operations.
- What general responsibilities DMERCs have for coordinating and sharing fraud-related information.
- How supplier alert information is incorporated into program integrity monitoring.
- What the periodic CMN validation review is intended to examine at a high level.
Who Should Read This
- Medicare compliance professionals
- DMEPOS suppliers
- Billing and coding staff
- Program integrity staff
- Auditors and investigators
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