Program Safeguard Contractor (PSC)
Program Safeguard Contractors (PSCs) were created to perform program integrity functions. The primary goal of PSCs is to investigate instances of suspected fraud, waste, and abuse. PSCs develop investigations early, and in a timely manner, take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid. They also identify any improper payments that are to be recouped by the MAC. Actions that PSCs take to detect and deter fraud, waste, and abuse in the Medicare Program include:
- Investigating potential fraud and abuse for CMS administrative action or referral to law enforcement;
- Conducting investigations in accordance with priorities established by CPI's Fraud Prevention System;
- Performing medical review, as appropriate;
- Performing data analysis in coordination with CPI's Fraud Prevention System;
- Identifying need for administrative actions such as payment suspensions and prepayment or auto-denial edits; and,
- Referring cases to law enforcement for consideration and initiation of civil or criminal prosecution.
In performing these functions, PSCs may, as appropriate:
- Request medical records and documentation;
- Conduct an interview;
- Conduct an onsite visit;
- Identify need for a prepayment or auto-denial edit and refer these edits to MAC for installation;
- Withhold payments; and,
- Refer cases to law enforcement.
PSCs also support victims of Medicare identity theft. A provider or supplier who believes that he/she may have had their provider information stolen and used to submit Medicare claims for which payment was made can request that the PSC for their zone investigate the case. The PSC will then work with CMS to determine the appropriate remedial action to assist the provider. Guidance on how to avoid and report Medicare identity theft and information on current scams can be found on the CMS website in the CMS Provider Victim Validation/Remediation Initiative – Medicare Program Integrity Contractor Points of Contact document.
The following are some of the major functions that the PSCs do not perform. These functions are performed by the MAC:
- Claims processing, including paying providers/suppliers;
- Provider outreach and education;
- Recouping monies lost to the Trust Fund (PSCs identify these situations and refer them to MACs for recoupment);
- Medical review not for benefit integrity purposes;
- Complaint screening;
- Claims appeals of PSC decisions;
- Claim payment determination;
- Claims pricing; and
- Auditing provider cost reports.
Last Updated Jun 17, 2016