In order to ensure the protection of the Medicare Trust Fund, Centers for Medicare & Medicaid Services (CMS) is interested in contracting with an outside entity to support CMS’ audit, oversight and antifraud and abuse efforts associated with the Prescription Drug Benefit (Part D), and the MA Program.
The Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC) shall provide a coordinated strategy to conduct proactive and reactive data analysis and identification of inappropriate payments, and potential program vulnerabilities in Medicare Parts C and Part D. The primary goal of the PPI MEDIC is to analyze Parts C and Part D data, conduct audits of plans, provide outreach and education and ensure compliance with regulatory requirements.
Additionally, while CMS’ oversight strategy is to monitor and address program integrity, identifying overall program vulnerabilities and ensuring plan sponsors’ adherence to regulatory requirements, technical assistance is necessary to assist the Agency in meeting these oversight responsibilities.
Services shall include, but are not limited to:
- Transition the Part C and Part D FWA detection and prevention workload from previous contractor;
- Perform proactive and reactive data analysis that may result in an audit (program, pharmacy, desk/ plan sponsor self- audit, etc.);
- Identify high risk plan sponsors, pharmacies, providers, and beneficiaries in Medicare Parts C and D;
- Develop and validate new and existing methodologies for the early detection and prevention of abusive use of services, as well as possible fraud and abuse schemes…
