Medicare Carrier – an entity that has a contract with CMS to determine and make Medicare payments for Part B benefits payable on a charge basis and to perform other related functions.
Medicare CMN Fraud – See Certificate of Medical Necessity in this Glossary.
Medicare Credit Balance Report – Submitted to CMS, the Report is supposed to contain “all Medicare credit balances shown in [the provider hospital’s] accounting records…as of the last day of the reporting quarter”–regardless of when they occurred and going back to the time when the provider began participating in the Medicare program. As with the Cost Report, the Credit Balance Report contains a statement to be signed by an officer or administrator of the provider certifying under penalty of criminal prosecution that “it is a true, correct, and complete statement prepared from the books and records of the provider in accordance with applicable Federal laws, regulations and instructions.” Many qui tam lawsuits have been brought alleging a provider’s failure to return Medicare Credit balances.
Medicare DHS Fraud – See Designated Health Services in this Glossary.
Medicare Fraud Lawyer – an attorney with expertise in the area of Medicare fraud, which would necessarily include healthcare fraud, medicare fraud and pharmaceutical fraud.
Medicare Integrity Program (MIP) contractor – These companies, on behalf of Medicare, conduct provider and supplier audits, medical reviews, cost report audits, beneficiary surveys, and provider education. CMS exercises the flexibility through MIP to contract with both Medicare claims processors and distinct fraud and abuse contractors to identify and root out improper payments. The Medicare Integrity Program was created as part of the Health Care Fraud and Abuse Control (HCFAC) program. The purpose of the MIP program is to ensure that Medicare outlays are made to the appropriate provider on behalf of eligible beneficiaries for covered services. Through HCFAC, the MIP program also coordinates with the HHS OIG, the FBI, and other fraud and abuse programs to ensure that all aspects of safeguarding payments are addressed — including preventing, identifying and/or resolving errors, fraud, waste and abuse.
Medicare Kickback – See Kickback Violation in this Glossary.
Medicare Overpayment – providers have a statutorily created duty to disclose overpayments and billing errors to the Medicare Carrier. Failing to return overpayments (commonly with cost reports) is a violation of the Federal False Claims Act and have been the subject of several qui tam lawsuits.
Medicare Part A Fraud – See Cost Report Fraud in this Glossary.
Medicare Patient Load – Relevant to a hospital’s cost reporting, it refers to the total number of hospital inpatient days during the cost reporting period that are attributable to patients for whom payment is made under Medicare Part A, divided by total hospital inpatient days. In calculating inpatient days, inpatient days in any distinct part of the hospital furnishing a hospital level of care are included and nursery days are excluded. When the Medicare patient load is fabricated to appear higher, or the non-Medicare load to appear lower, false claims have been submitted in violation of the False Claims Act.
Medicare Secondary Payer – Overpayments generally result when payment is made by Medicare for noncovered items or services, when payment is made that exceeds the amount allowed by Medicare for an item or service, or when payment is made for items or services that should have been paid by another insurer (Medicare secondary payer obligations). Once a determination and any necessary adjustments in the amount of the overpayment have been made, the remaining amount is a debt owed to the United States Government Questions to ask include, is the provider inappropriately billing Medicare first, when Medicare payments for such beneficiaries are required to be secondary to certain types of private insurance coverage. How does the provider resolve credit balance situations?
Medicare supplemental (or Medigap) policy – this is a health insurance policy/health benefit plan offered by private health insurance companies, which is primarily designed, (or is advertised and marketed) to provide payment for expenses incurred for services and items that are not reimbursed under the Medicare program because of deductibles, coinsurance, or other limitations under Medicare. Medicare pays a capitated rate for each beneficiary who enrolls in such a plan. Fraud, where it occurs, often involves underserving the Medicare beneficiary.