Updated October 25, 2019
The overall purpose of the Plan Program Integrity Medicare Drug Integrity Contract (PPI MEDIC) is to support the Centers for Medicare and Medicaid Services (CMS) in their efforts to proactively detect and prevent fraud, waste, and abuse (FWA) in Medicare Part C and Part D. The contractor shall support CMS by conducting proactive and reactive data analysis within Medicare Parts C and D and identifying program vulnerabilities. The PPI MEDICs preliminary findings shall be provided to Medicare Advantage (MA) and Prescription Drug Plans (PDP) for further review, analysis, and corrective actions as needed to support their overall FWA monitoring efforts.
In order to ensure the protection of the Medicare Trust Fund, CMS is interested in contracting with outside 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. This entity will hereafter be referred to as the PPI MEDIC. The PPI MEDIC is a national contractor.
The 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. Services under this Statement of Work (SOW) shall provide a full range of statistical, analytical, and/or professional business functions to CMS. Services shall also address program focal areas in management, administration, operation and oversight of the Medicare Parts C and D programs. 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…
Posted August 16, 2019
Re: Solicitation Number: 75FCMC19R0042
The Centers for Medicare & Medicaid Services (CMS) will be issuing a Request for Proposal (RFP) to solicit services for the Plan Program Integrity Medicare Drug Integrity Contract (PPI MEDIC). The overall strategy for the PPI MEDIC is to conduct proactive and reactive data analysis within Medicare Parts C and D and identify any program vulnerabilities. These findings shall be provided to the Medicare Advantage and Prescription Drug Plans for further review, analysis, and corrective actions as needed to support their overall fraud, waste, and abuse monitoring efforts…
The solicitation will be available on or about September 3rd, 2019, and it will be distributed solely through the Federal Business Opportunities (FBO) website.
