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42 U.S. Code § 1395ddd. Medicare Integrity Program
(a) Establishment of Program
There is hereby established the Medicare Integrity Program (in this section referred to as the “Program”) under which the Secretary shall promote the integrity of the medicare program by entering into contracts in accordance with this section with eligible entities, or otherwise, to carry out the activities described in subsection (b).
(b) Activities describedThe activities described in this subsection are as follows:
(1)
Review of activities of providers of services or other individuals and entities furnishing items and services for which payment may be made under this subchapter (including skilled nursing facilities and home health agencies), including medical and utilization review and fraud review (employing similar standards, processes, and technologies used by private health plans, including equipment and software technologies which surpass the capability of the equipment and technologies used in the review of claims under this subchapter as of August 21, 1996).
(2)
Audit of cost reports.
(3)
Determinations as to whether payment should not be, or should not have been, made under this subchapter by reason of section 1395y(b) of this title, and recovery of payments that should not have been made.
(4)
Education of providers of services, beneficiaries, and other persons with respect to payment integrity and benefit quality assurance issues.
(5)
Developing (and periodically updating) a list of items of durable medical equipment in accordance with section 1395m(a)(15) of this title which are subject to prior authorization under such section.
(6)
The Medicare-Medicaid Data Match Program in accordance with subsection (g).
(c) Eligibility of entitiesAn entity is eligible to enter into a contract under the Program to carry out any of the activities described in subsection (b) if—
(1)
the entity has demonstrated capability to carry out such activities;
(2)
in carrying out such activities, the entity agrees to cooperate with the Inspector General of the Department of Health and Human Services, the Attorney General, and other law enforcement agencies, as appropriate, in the investigation and deterrence of fraud and abuse in relation to this subchapter and in other cases arising out of such activities;
(3)
the entity complies with such conflict of interest standards as are generally applicable to Federal acquisition and procurement;
(4)
the entity agrees to provide the Secretary and the Inspector General of the Department of Health and Human Services with such performance statistics (including the number and amount of overpayments recovered, the number of fraud referrals, and the return on investment of such activities by the entity) as the Secretary or the Inspector General may request; and
(5)
the entity meets such other requirements as the Secretary may impose.
In the case of the activity described in subsection (b)(5), an entity shall be deemed to be eligible to enter into a contract under the Program to carry out the activity if the entity is a carrier with a contract in effect under section 1395u of this title.