Program Integrity: Medicare

Scope and purpose.

This provision outlines the scope and purpose of Medicare requirements for providers to disclose ownership and control information to protect program integrity.

Purpose.

This provision implements Social Security Act requirements for providers to disclose ownership, control, and managing employee information, including criminal history.

Definitions.

This provision defines key terms such as agent, disclosing entity, managing employee, and ownership interest for Medicare program integrity purposes.

Determination of ownership or control percentages.

This provision specifies the methodology for calculating indirect ownership interests and percentages for Medicare disclosure requirements.

Disclosure of hiring of intermediary's former employees.

This provision requires providers to notify the Secretary when hiring individuals who were recently employed by a Medicare fiscal intermediary or carrier.

Principals convicted of a program-related crime.

This provision mandates the disclosure of principals convicted of program-related crimes and authorizes CMS to refuse or terminate agreements based on such convictions.

Disclosure by providers and part B suppliers of business transaction information.

This provision requires providers to submit information regarding business transactions with subcontractors and wholly owned suppliers upon request.

Disclosure of persons having ownership, financial, or control interest.

This provision details the specific information, timing, and manner for disclosing ownership and control interests to CMS or state survey agencies.

Other related regulations.

This provision cross-references other regulations regarding appeals procedures and exclusions from the Medicare program.

Basis, purpose, and scope.

This provision outlines the requirement for providers to grant the Secretary and Comptroller General access to contracts and records to verify costs.

Definitions.

This provision defines key terms such as subcontractor, provider, and contract for services as they relate to Medicare program integrity and record access requirements.

Requirement for access clause in contracts.

Providers must include a clause in contracts with subcontractors that grants HHS and the Comptroller General access to books, documents, and records for four years.

HHS criteria for requesting books, documents, and records.

HHS will request records from a subcontractor only when specific conditions are met, such as suspected excessive costs, insufficient information, or allegations of illegal activities.

Procedures for obtaining access to books, documents, and records.

This provision details the formal procedures for HHS to request access to records and the corresponding obligations of the subcontractor to provide them.

Basis and scope.

This provision establishes the authority for CMS to implement programs that encourage reporting of suspected fraud and abuse and provide rewards for such information.

Rewards for information relating to Medicare fraud and abuse.

CMS provides monetary rewards for information leading to the recovery of Medicare funds, subject to specific eligibility criteria and submission procedures.

Establishment of a program to collect suggestions for improving Medicare program efficiency and to reward suggesters for monetary savings.

This provision establishes a CMS program to collect and reward suggestions that improve Medicare program efficiency and result in monetary savings.