Introduction

4.1 – Introduction (Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23) The CMS Pub. 100-08, Program Integrity Manual (PIM), reflects the principles, values, and priorities of the Medicare Integrity Program (MIP). The primary principle of program integrity (PI) is to pay claims correctly. To meet this goal, Unified Program Integrity Contractors (UPICs), Investigations Medicare Drug Integrity Contractor (I- MEDIC), Supplemental Medical Review Contractors (SMRC) and Medicare Administrative Contractors (MACs) must ensure that Medicare pays the right amount for covered and correctly coded services rendered to eligible beneficiaries by legitimate providers. The focus of the UPICs, SMRCs and MACs shall be to ensure compliance with Medicare regulations, refer suspected fraud and abuse to our Law Enforcement (LE) partners, and/or recommend revocation of providers that are non-compliant with Medicare regulation and policies. The Centers for Medicare & Medicaid Services (CMS) follows four parallel strategies in meeting this goal: 1. Prevent fraud through effective enrollment and education of providers/suppliers and beneficiaries; 2. Encourage early detection (through, for example, the Fraud Prevention System (FPS), medical review (MR) and data analysis); 3. Coordinate closely with partners, including other UPICs, SMRCs, MACs, LE agencies, and State PI units; and 4. Enact fair and firm enforcement policies. The UPICs shall coordinate with their Contracting Officer’s Representative(s) (COR) and their Business Function Lead(s) (BFL) to fulfill all direction as described in the PIM. For all guidance and instruction described in this chapter, the UPIC shall directly contact the appropriate UPIC BFL, with a copy to the UPIC COR, for any Technical issues and/or questions (i.e. process related issues/inquiries, workload prioritization, etc.). Additionally, the UPIC shall directly contact the UPIC COR, with a copy to the appropriate UPIC BFL, for any Business issues and/or questions (i.e., level of effort concerns, funding issues, etc.). The UPICs shall follow the PIM to the extent outlined in their respective task orders’ Statement of Work (SOW). The UPICs shall only perform the functions outlined in the PIM as they pertain to their own operation. The UPICs, in partnership with CMS, shall be proactive and innovative in finding ways to enhance the performance of PIM guidelines. For this entire chapter, any reference to UPICs shall also apply to the I-MEDIC, unless otherwise noted or identified in the Contractors’ SOW. MACs shall follow the PIM in accordance with their SOW. To facilitate understanding, the terms used in the PIM are defined in PIM Exhibit 1. The acronyms used in the PIM are listed in PIM Exhibit 23.