Fraud is the intentional deception or misrepresentation of facts that an individual or an organization perpetrates for the purpose of gaining an otherwise unauthorized or illegitimate benefit for himself/herself, some other person, or an organization. Abuse involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments. The real difference between fraud and abuse is the person's intent. Both have the same impact: they detract valuable resources from the Medicare Trust Fund that would otherwise be used to provide care to Medicare beneficiaries.

The role of the UPIC is to help address fraud, waste and abuse (FWA) by performing regional Medicare and Medicaid data analysis, complaint resolution and investigative activities. These and other techniques are also used to identify Medicare and Medicaid program weaknesses and vulnerabilities.

The acceptance or offering of “Kickbacks”. Routine waiver of co-payments, falsifying certificates of medical necessity, plans of care and other records, billing for services not rendered, misrepresenting the diagnosis to justify payment, and beneficiaries sharing Medicare cards are just some of the more common schemes.

Review your Medicare Summary Notice when you receive it, and make sure you understand all of the items listed. If you don’t remember a procedure that is listed, you should first call your physician, provider, or supplier that is listed on the Medicare Summary Notice. Many times a simple mistake has been made and can be corrected by your physician, provider, or supplier’s office when you call. If your physician, provider, or supplier’s office does not help you with the questions or concerns about items listed on your Medicare Summary Notice and you still suspect Medicare fraud or if you cannot call them, you should call or write the Medicare company that paid the claim. The name, address, and telephone number are on the Medicare Summary Notice (MSN) you receive, which shows what Medicare paid.

Before contacting the Medicare claims processing company, carefully review the facts as you know them and as shown on the Medicare Summary Notice. Write down:
• The provider's name and any identifying number you may have.
• The item or service you are questioning.
• The date on which the item or service was supposedly furnished.
• The amount approved and paid by Medicare.
• The date of the Medicare Summary Notice.
• The name and Medicare number of the person who supposedly received the item or service.
• The reason you believe Medicare should not have paid.

The MACs are responsible for all other functions not specifically assigned to the UPIC by the Statement of Work, including claims processing, customer service, select pre- and all post-payment medical review functions, appeals, provider enrollment, financial accounting, Medicare Secondary Payer (MSP) and related provider education and beneficiary outreach activities. The MACs are also responsible for referring any suspected fraudulent or abusive situations or patterns by providers or beneficiaries in the Medicare program to the UPIC.

QIOs are focused more on quality improvement projects in relation to medical review, medical necessity and quality of care issues. Unlike the UPICs, the QIOs are not charged with proactively identifying fraud. However, the QIO is permitted to make referrals to the UPIC for benefit integrity issues. Likewise, the UPIC may refer cases to the QIO for medical necessity and quality of care issues.

The Comprehensive Error Rate Testing (CERT) Program produces national, contractor specific, service specific and provider type paid claim error rates. Systematic random samples of claims from the MACs are periodically reviewed by the CERT in order to evaluate the accuracy of Medicare Fee-for-Service payments.

Cases typically get referred from the MACs as a result of beneficiary, provider and whistleblower complaints. Cases may also be referred from the Office of Inspector General (OIG) Hotline and CMS Fraud Alerts.

​You may receive requests for copies of medical records from the MACs, the CERT, or the UPIC. Letters from each entity will be sent on letterhead for identification purposes with the appropriate contact information contained therein. Any of these record requests should be returned within the specified time period.