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Other Review Entities

Type of Review

Contractor

Brief Description

Comprehensive Error Rate Testing (CERT)

AdvanceMed

CERT was established by CMS to monitor and report the accuracy of Medicare Fee-For-Service (FFS) payments. It calculates the paid claims error rate for Medicare claims submitted to Part A, Part B and DME MACs.

Office of Inspector General (OIG)

OIG

The OIG's duties are carried out through a nationwide network of audits, investigations, inspections and other mission-related functions performed by OIG components. (Public Law 95-452 (as amended)).

Recovery Auditor


HealthDataInsights

The Recovery Auditor detects and corrects past improper payments so that CMS, claims processing contractors, and suppliers can implement actions that will prevent future improper payments.

Supplemental Medical Review Contractor (SMRC) StrategicHealthSolutions, LLC The SMRC does nationwide medical review for all types of Medicare claims, including DME claims, as directed by CMS.

Zone Program Integrity Contractor (ZPIC)

SafeGuard Services (SGS) This link will take you to an external website.

AdvanceMed This link will take you to an external website.

The primary goal of ZPICs is to investigate instances of suspected fraud, waste, and abuse. They also identify any improper payments that are to be recouped by the MAC.

  • SafeGuard Services (SGS) – CA, HI, NV
  • AdvanceMed – AK, AZ, IA, ID, KS, MO, MT, NE, ND, OR, SD, UT, WA, WY

 

Last Updated Feb 20, 2017