What’s Your Status?Critical Success Factors in Effectively

Determining Inpatient versus Observation Status and Enhancing Compliance

Presentation by Carol D. Eaton, CPAMCitrus Valley Health Partners

HFMA / AAHAMNovember 18th, 2010

Introduction to Observation Status

Observation services are those services furnished by a hospital on the hospital’s premises, including use of a bed and at least periodic monitoring by a hospital’s nursing or other staff which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for possible admission to the hospital as an Inpatient. State licensure/staff bylaws to perform this service are required.

GOALS• Understand the difference in the terms “Observation” vs.

“Inpatient” and “Outpatient referrals”• Apply documentation requirements that will support

Observation services• Documentation requirements for Nursing, Physicians

and why it’s so important• Become aware of additional services that should be

reported while the patient is in Observation.• What is “medically necessary”• Detect, create, enhance processes to meet regulatory

guidelines to improve the financial bottom line

Introduction to Observation StatusObservation Care (Outpatient)

• Patients can be evaluation or treated within 24-48 hours. Recovery is not Observation.

• Rapid Improvement is anticipated with 24-48 hours• Patient experiences postoperative complication that

require further monitoring to decide if admission is necessary (Post-OP i.e.,bleeding, vomiting past 4-6 hours)

• Care Coordination InterQual/Milliman shows Observation status indications (Chest pain, Asthma, CHF)

• Orders written: “Observation” “Observation Status” “Observation Service”, with medical necessity indications documented, timed, dated, physician signature

Introduction to Observation StatusTypical conditions that warrant Observation Status:

Abdominal pain not requiring surgeryAllergic reaction, generalizedAltered mental statusAnemiaBack painChest painCHFGI conditionsNutritional & metabolic disordersHypertensionHeadache, unknown etiologyShortness of breath

If in question call your Case Manager/Coordinator and/or attending physician. Do not base any status on a list of “Typical conditions”.

Introduction to Observation StatusMost observation services do not exceed 24 hours. Some patients,

however, may require 48 hours of outpatient observation services. In only rare and exceptional cases do outpatient observation services span more than 48 hours.

Observation services more than 48 hours may lead to an additional document review (ADR) to prove necessity is documented.

Healthcare Association letters to Marilyn Tavenner, CMS Principal Deputy Administrator: (Observation past 48hr)

http://www.aha.org/aha/letter/2010/101027-let-pollack-cms.pdfhttp://www.fah.org/fahCMS/Documents/On%20The%20Record/Pub

lic%20Comments/2010/M_Tavenner_Ltr.pdf

Introduction to Observation Status

Charges for Observation include:

G0378 Hospital observation per hour

G0379 Direct admission ONLY-The patient directed to the hospital for observation (these are patients that usually come directly from the physician office (not to be used when coming from the ER) No additional charge or reimbursement if a patient comes from ER.

Introduction to ObservationOverview

CMS Pub 100-04 Transmittal #1445 2008Observation care is a well-defined set of specific,

clinical appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatient or if they are able to be discharged.

Observation must be reasonable and necessary to be covered.

General standing orders for observation services following all outpatient surgeries are not recognized

Introduction to ObservationOverview

Physician documentation:• Clear and concise orders• Patient must be in the care of a physician during

the period of observation, and documented in the medical record.

• Progress, admission and discharge notes must be timed, written, and signed by the physician

• Documentation that the physician explicitly assessed patient risk to determine that the patient would benefit from observation. Goal for the care.

Introduction to ObservationReporting Hours

Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time the patient is placed in a bed for the purpose of initiating observation care in accordance with a physician’s order. Orders can not be retroactive.

Hospitals should round to the nearest hour.Observation time ends when all medically necessary

services related to observation care are completed. Waiting time or pick-up time are not included in the hours calculated.

If the period of Observation spans more than one calendar day, all of the hours for the entire period are reported as a single line with the date the Observation care begins.

Introduction to ObservationReporting Hours

Other issues that interrupt/stop the hourly Observation charge with HIGH importance:

“Significant Monitoring Service”• IV medication given with significant monitoring, then the

time should be subtracted from the observation hourly count. (IOM 100-04,Chapter 4,section 290.2.2) infusion, hydration, Chemo. Not routine antibiotics, but those requiring significant monitoring.

(Start, stop, date, route, signature are required on all drug/solution documentation)

• Observation hours interrupt / stop during operative/surgery procedures (biopsy, chemo, endoscopies, radiation therapy). This does NOT include basic x-ray, lab-they are not considered monitored.

Inpatient found to be an Observation before discharge ?

Some instances occur where the physician may order a patient to be admitted to an Inpatient bed, but upon reviewing the case later, the hospital’s utilization review committee determines that an Inpatient level of care does not meet the hospital’s admission criteria. Do not charge Observation hours on these charts during the Inpatient portion of services. Clock time/date begins in accordance with the physician’s order and Observation initiation.

Medicare requires the use of the billing “code 44” when the following conditions are met:

1. The change Inpatient status from Inpatient to Observation/Outpatient is made prior to discharge or release, while the patient is still in the hospital;

2. The hospital has not submitted a claim to Medicare for the Inpatient admission;3. A physician concurs with the utilization review committee’s decision; and4. The physician’s concurrence with the utilization review committee’s decision is

documented in the patient’s medical records.https://www.cms.gov/transmittals/downloads/R299CP.pdfhttps://www.cms.gov/MLNMattersArticles/downloads/SE0622.pdf

CONSULT CASE MANAGEMENTWhen these conditions are met, the entire episode of care should be treated as though

the Inpatient admission never occurred. Services provided prior to Observation order can be billed as Outpatient. No observation hours until ordered.

Physicians/Nursing Working Together

• Nursing documentations is tied to the physician orders

• Nursing will help keep the physician involved in the status of the original order being met and requesting a new status such as discharge home, admit inpatient and or a change in orders

• Nursing will have ongoing discussions with the physician such as updating the physician on the patient’s status and receiving new orders

• Nursing/Physicians/Care Coordinators keep the patient informed of their Admit/ Observation/ Outpatient status. Part of the patient’s right to know and be informed.

Observation NO-NO-NEVERS• “Admit to Outpatient Status”• “Admit to Observation Status” “23 hour”

– (admit means IP, Observation/Outpatient means OP, conflicts in terminology)

• Put every patient of same type in Observation status• Use Observation status for expected long post operative

stay• Use Observation when you know patient needs to be an

Inpatient. (check with Care Coordination)• Convenience of patient, family or physician. Holding

zone use.• Awaiting placement to long-term care facility• Stay past 48 hours without extensive medical necessity

and documentation.• Basic procedure recovery (approx 4-6 hours)

Inpatient Admission StatusInpatient

• Physician does not expect patient to be evaluated or treated within 24 hours

• Rapid improvement is not anticipated for the patient within 24-48 hours

• Care Coordination InterQual/Milliman shows Inpatient status indications

• Orders “Admit” Acute and meets criteria of inpatient • RAC denials with absence of sufficient documentation

for medical necessity, are never overturned on appeal. Documentation must be there or the recoupment is 100 percent of the claim.

• Medicare’s Program Integrity Manual (Chapter 6,Section 6.5.2.) Basic rules of medical records sufficient documentation to demonstrate that the beneficiary warrants admission– http://www.cms.gov/manuals/downloads/pim83c06.pdf

Inpatient Admission StatusInpatient

• Patients must have orders changing from Observation/Outpatient to Admit (Inpatient) status by a physician. Protocols do not equal orders.

• The admission and bill date begin at the time of this order. Order can not be retroactive. The registration date MUST be changed (from the Outpatient encounter date) to this admit date so the claim admission date coincides with the orders on file.

• If admitted, hospital bills for admission only at the time of order/date (even if the previous status is Observation/ Outpatient for 24+ hours)

• Admission day count begins at the time of the orders for “Admit” and complies with medical necessity standards (InterQual/Milliman review with physician for documentation and supporting criteria)

• Some surgical services are considered “C=Inpatient Only Procedures” codes. Generally considered an inpatient only after a physician issues an order, a written physician order for Inpatient must precede an inpatient-only procedure. Medicare Claims Processing Manual, Chapter 3, Section 40.2.2K. If the physician issues the order after the procedure, the hospital will acknowledge a denial. Orders after the procedure are considered backdated and not allowed by CMS guidelines. See the manual chapter 3 for exceptions to the rule.

Basic Referred OutpatientOutpatient Status

• Chemotherapy• Biospy (cysts, liver, trocar, breast, bone marrow, kidney)• Transfusion-blood (patient scheduled to come in for basic transfusion)• Injection/Infusion/Hydration• Pain pump refill• Paracentesis• Plasmapheresis• Thoracentesis• Lavage/drainage bladder etc• Spinal tap• Bronchoscopes• Insertion of access device

Normal referrals for these services are outpatient medical procedures and basic recovery is included unless complications go past the normal recovery period of 4-6 hours. Observation status would require extensive documentation to prove medical necessity along with an specific order (time, dated, medical necessity/goal, signature)

Education/Improvement• Admission status criteria can be published, generally accepted medical

standards (InterQual or Milliman) or pre-established, hospital-specific standards.

• Admitting physicians, either ED or Primary Care MDs, must record orders clearly and consistently with criteria followed by all medical staff for a facility.

• Case Managers and ED nursing staff assisting with physician determinations of “medical necessity” for admission status.

• Documentation audit and education sessions for all staff and physicians. Deploy specialists in risk areas. (i.e.,cardiology,wound care, lab)

• Review PEPPER reports to benchmark performance• Analyze areas for improvement, potential risk types, peer review and trending. • Report development of Observation, one-day stays, 2-4 day stays, Outpatient

surgery types that are admitted.• Review ALL RAC websites and review DRG cases in your specific facilities.

Watch for Medicaid RAC in the near future. Include all audit type websites and notices.

• Constant access to CMS, OIG, MIG websites for transmittals,MLN, One-time notices, OPPS, IPPS, LCD, NCD documents.

• Patient notification: http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf

Track and Control• Mortality rates, readmissions and HACs by physician, trending by

discharge date• Auditor take-backs-medical necessity trending by discharge date• MS-DRG trending by discharge date• Number of one-day stays by case manager/physician/discharge

date• IP/OP/Observation rates compared to your monthly census, trended

by discharge date• Physician advisor ongoing initiative and trend findings.• Documentation support systems, payer specific or top denial rate

MS-DRGs• Audit HIM coding, document back-up, track findings and analyze

with reporting to medical staff and medical executives.• Charge Capture is essential to avoid hospital overall financial

vulnerabilities. Meetings, statistics, reports and performance accountability.

• 3rd party audits for HIM, Chargemaster, Charge capture risk areas

Defenses• ALJ are objective in decisions• Look at the effective date of Medicare payment criteria

vs. date of service (LCD/NCD)• Challenge whether the RAC used a certified coder or

physician in its review• Statistical sampling/extrapolation-Challenge the methods

used by the RAC. ALJ must review each claim• 3 year look back-Medicare (limited to 10/1/07)• 5 year look back-Medicaid-date of audit Notification letter

is issued to provider• Waiver of Liability (Section 1879)-Limits liability of the

provider if services are found to be not medically reasonable & necessary, if the provider did not know or could not reasonably been expected to know that the services were not covered.

Defenses• Without Fault (Section 1870)-a provider will be deemed to be without

fault if notice of overpayment is 3 or more years from initial payment.• CFR (405.980)-Reopen within one year of initial determination for

any reason• Good Cause for Reopening-MAC may reopen a claim within 4 years

from the date of the initial determination for good cause.• Good cause may be established if: (1) there is new & Material

evidence that (i) was not available or known at the time of determination; and (ii) may result in a different conclusion; or (2) the evidence that was considered clearly shows on its face an obvious error.

• Not an appealable issue for the ALJ-CMS’s evaluation and monitoring of the RAC performance, not the appeals process, offered the forum for enforcing the good cause standard

Defenses by Renee Jordan, Esq & Bacen & Jordan,P.A. (Frt L.,Florida)

Medical Necessity Reminder– The Medicare Benefit Policy Manual 100-02, Chapter

1 Inpatient Hospital Services Covered Under Part A states the following:

• “The physician or other practitioner responsible for patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis. However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting. Factors to be considered when making the decision to admit include such things as:

Medical Necessity Reminder• The severity of the signs and symptoms exhibited by the

patient;• The medical predictability of something adverse

happening to the patient;• The need for diagnostic studies that appropriately are

outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and

• The availability of diagnostic procedures at the time when and at the location where the patient presents.

DOCUMENT THIS INFORMATION IN THE CHART>>>>

Medical Necessity Reminder• Under original Medicare, the Quality Improvement

Organization (QIO), for each hospital is responsible for deciding, during review of inpatient admissions on a case-by-case basis, whether the admission was medically necessary. Medicare law authorizes the QIO to make these judgments, and the judgments are binding for purposes of Medicare coverage. In making these judgments, however, QIOs consider only the evidence which was available to the physician at the time of admission decision had to be made. They do not take into account other information (e.g., test results) which became available only after admission, except in cases where considering the post-admission information would support a finding that an admission was medically necessary.”

UR Committee and CoP’s• UR Committees composition and rules are found in 42 Code of

Federal Regulations (CFR) Sections §456.105-456.106 and§482.30

• The Conditions of Participation (CoP) in §482.30 of the regulations requires that the utilization review committee be comprised of at least two doctor of medicine or doctors of osteopathy, although it may include other specified practitioners. The CoP provides that the determination concerning the medical necessity of an admission or continued stay must be made by members of the UR committee.

• CMS can and may impose enforcement /CMPs when it determines that a facility is not in “substantial compliance” with one or more participation requirements. 42 C.F.R. § 488.402. “Substantial compliance” = a level of compliance such that “any identified deficiencies pose no greater risk to resident health or safety than the potential for causing minimal harm.” 42 C.F.R. § 488.301. Under the regulations the term “noncompliance” refers to “any deficiency that causes a facility to not be in substantial compliance.”

CMSQuestions/Answers

• Q-If an IP/admit is determined after the discharge the patient should have been observation or outpatient, do we still bill for it?– A patient status can not be changed to observation/outpatient

after a patient is discharge. Medicare can only be billed for Part B only services on a 121 claim Lab, X-ray

• Q-What physician has to be in-house during an observation visit?– A It does not have to be the attending physician, the

physician/NPP that physician assigned must be immediately available. Federal Register, 74FR 60582-60583 http://frwebgate.access.gpo.gov/cgi-bin/getpage.cgi

• Q-Can we bill for anything other than just Observation?– A Hospitals should bill all of the other services associated with

the observation care, including direct admission, ER, Critical care. If observation care doesn’t meet all requirements then payment may be packaged into payments for other separately payable services for the patient encounter.

CMSQuestions/Answers

National Government Services (NGS), the MAC for jurisdictions 8 (Wisconsin and Indiana) and 13 (New York and Connecticut), recently questioned its CMS representative about this issue, and the representative confirmed this opinion. NGS shared the following:

“We received confirmation from our CMS representative that indeed, a written order for observation status is required and that the inpatient stay cannot be converted to observation time when CC 44 is applicable. If the physician (or UR committee in conjunction with the phy6sician) deems the patient meets observation criteria after conversion to outpatient status, then observation time may be billed if the level of care is met. BUT< observation time would begin when the order is written; and the previous (although incorrect) inpatient time could no9t be billed as observation,. The services rendered while the patient was placed in inpatient status would be billed as outpatient services, but no observation time could be billed.

Although this confirmation is applicable only to the NGS jurisdictions, note that NGS received this clarification from CMS.

Additionally, since that time, Noridian Administrative Services, the MAC for jurisdiction 3 and 6, has also confirmed to providers in its jurisdiction that this is the correct billing for observation hours.

If providers receive conflicting advice from their MAC, I would encourage them to use CAUTION in billing any hours of observation WITHOUT A PROPER ORDER for observation services, especially in light of CMS confirmation to NGS.

Complex Medical Necessity Reviews

• CMS released the first of three articles addressing high-risk vulnerabilities in July 2010.

• SE1024 - Focused on documentation risk http://www.cms.gov/MLNMattersArticles/downloads/SE1024.pdf

• SE1027 and SE1028 - Insufficient documentation considerations set forth in the first MLN.– https://www.cms.gov/MLNMattersArticles/downloads/SE1027.pdf– http://www3.cms.gov/MLNMattersArticles/downloads/SE1028.pd

f (Updated 10/29/10)– http://www.cms.gov/manuals/downloads/pim83c06.pdf– http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

• Signature Guidelines for Medical Review (legibility)– http://www.cms.gov/transmittals/downloads/R327PI.pdf– http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/

84HT746343• Clinical Review Judgment

– http://www.cms.gov/transmittals/downloads/R338PI.pdf

Other Impacting Topics to Consider• 3 Day Rule Changes http://www1.cms.gov/transmittals/downloads/R796OTN.pdf• ABN:Advanced Beneficiary Notice

http://www.medicarefind.com/searchdetails/Transmittals/Attachments/R1921CP.pdf

• Shadow Claim-Encounter data submission• Medi-Cal-No recognition of Observation• Insurance/IPA notification of Observation and repeat if admission• HINN vs ABN? MM6563• How will Observation impact 3 day requirement for SNF• Insurance contracting/reimbursement?• Joint Commission Standards: RC.01.02.01 Entries in the medical record are

authenticated by the author. 2010 CSR • Informing patients of status changes?

http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf• Medicare Quarterly Provider Compliance Newsletter, CMS

http://www4.cms.gov/MLNProducts/downloads/MedQtrlyComp_Newsletter_ICN904943.pdf

• Physician Supervision and H.R. 6376 ( www.thomas.gov )• Self Administered Drugs on Observation

http://www.medicare.gov/Publications/Pubs/pdf/11333.pdf

RAC Regions

• • Diversified Collection Services, Inc. of Livermore, California, in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.

• • CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota.

• • Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.

• • HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.

• 1st-2nd Quarter Dollar Value Automated/Complex Denials• Region A $1.3 million• Region B $2.1 million• Region C $10.9 million• Region D $4.9 million

Other Pre & Post Payment Review Types

• NCCI National Correct Coding Initiatives (Medicare and now Medicaid)

• MUE Medically Unlikely Edits• UOS Units of Service Edits• MAU Maximum Allowed Units• MSP Medicare Secondary Payer

IV Drugs to Audit for dosage and multiplier

• J9265 30mg Paclitaxel (Taxol) • J9055 10mg Cetuximab (Erbitux)• J9264 1mg Paclitaxel P-B p (Abraxane)• J3101 1mg Tenectplase (TNKase)• J2430 30mg Pamidronate Disodium (Aedia)

• J0150 6mg Adenosine (Adenoscan/Adenocard)

• J0152 30mg Adenosine(Adenoscan/Adenocard)

• J3488 1mg Zoledronic Acid (Reclast)

New Implementation for 2010-2011Medicaid & Medicare Providers

• Single State Agency: Program Integrity Unit• State Pay and Chase Program by State Auditor or

Comptroller or IG• HHS OIG

– AG Medicaid Fraud Control Units: funded by OIG. Run by states to investigate and audit

– Federal Investigators/auditors/contractors – NEW +$25 Million to enforce and audit Medicaid

• CMS-Medicaid Integrity Group (MIG)– NEW PERM Auditors 23 month cycle-Indentify overpayments-

state must collect them. Set State/Program Error Rate– NEW MIP Auditors-High ROI-Project based for MIP Division– State run RAC programs for Medicaid

• CMS-Medicare– ZPICS & RACS, QIOs and CPC

Medicaid State RAC• According to the CMS release in the Federal Register, the forms are intended for the

preparation of the RAC expansion into Medicaid, as required by the Patient Protection and Affordable Care Act:

• Under section 1902(a)(42)(B)(i) of the Social Security Act, States are required to establish programs to contract with one or more Medicaid RACs for the purpose of identifying underpayments and recouping overpayments under the State plan and any waiver of the State plan with respect to all services for which payment is made to any entity under such plan or waiver. Further, the statute requires States to establish programs to contract with Medicaid RACs in a manner consistent with State law, and generally in the same manner as the Secretary contracts with Medicare RACs.

• State programs contracted with Medicaid RACs are not required to be fully operational until after December 31, 2010. States may submit, to CMS, a State Plan Amendment (SPA) attesting that they will establish a Medicaid RAC program. States have broad discretion regarding the Medicaid RAC program design and the number of entities with which they elect to contract.

• http://edocket.access.gpo.gov/2010/pdf/2010-22593.pdf• California Zone 1 ZPIC

2011 Updates + more• Medi-Cal Eligibility regulations 2009

– http://info.sen.ca.gov/pub/09-10/bill/asm/ab_1101-1150/ab_1142_cfa_20090623_131445_sen_comm.html

• Correct Reporting of Biologicals when used as implanted devices https://www.cms.gov/MLNMattersArticles/downloads/MM7117.pdf Expansion of the Current Scope of Editing for Attending Physician Providers

– MM6856 CR6856 https://www.cms.gov/MLNMattersArticles/downloads/MM6856.pdf

– MM7046 http://www.cms.gov/MLNMattersArticles/downloads/MM7046.pdf• Clarification of payment window for Outpatient treated as Inpatient services

– http://www1.cms.gov/transmittals/downloads/R796OTN.pdf• NUBC Point of Origin Code Update

http://www.cms.gov/transmittals/downloads/R793OTN.pdf• Claim Status Category & Claim Status codes Update

https://www.cms.gov/transmittals/downloads/R2049CP.pdf• POA Indicator (1) change to (Blank)

https://www.cms.gov/MLNMattersArticles/downloads/MM7024.pdf• Revenue Codes Update

https://www.cms.gov/MLNMattersArticles/downloads/MM7100.pdf

Supporting Documentation• CMS Manual System Pub 100-04 & Chapter 6,Section 70.4 + more

– Transmittal #1445 CR 5946– Transmittal #299 CR 3444– Transmittal #1803 – Transmittal #1760 – MLN Matter MM6492 CR 6492– www.noridianmedicare.com/provider/updates/docs/QA_Observation_pdf Feb

15,2010• Hcpro.com Briefings on APC Nov 1,2009• Hcpro Revenue Cycle Institute Article Oct 2009 “Inpatient or Outpatient Only: Why

Observation has lost its status”• CMS Palmetto GBA “inpatient, outpatient, observation” presentation

– March 19,2009 Fresno Heart Hospital• MedLearn “Hospital Observation Services” 2009• MedLearn Letter to CMS June 2009• Federal Register, Vol 73, November 18,2008 Rules and Regulations• CMS Product # 11435 December 2009 “Are you a Hospital Inpatient or

Outpatient?” (For patient distribution)

• Disclaimer: This document was designed to provide accurate information as a tool for your use. Carol Eaton, CVHP, agents and staff, make no representation, guarantee or warranty, express or implied, that this is error-free, and will bear no responsibility or liability for the results of it’s use. However, the ultimate responsibility for accuracy lies with the user. This is not be copied, distributed or sold without the expressed consent of Carol Eaton 626-732-3103

Descriptions• CMS- The Centers for Medicare and Medicaid Services• MAC-Medicare Administrative Contractors (B-Carriers/A-Intermediaries)• HHS-Health and Human Services• IG-Inspector General• AG-Attorney General• MIG-Medicaid Integrity Group & Medicaid Inspector General• MIC-Medicaid Integrity Contractors• MIP-Medicaid Integrity Program• ROI-return on investment• ZPIC-Zone Program Integrity Contractors (previously Program Safeguard

Contractors PSC) (HOT: California, Florida, New York, Illinois and Texas)• RAC-Recovery Audit Contractors (HDI=HealthData Insights-Region D)• QIO-Quality Improvement Organization (HSAG)• NCQA-The National Committee on Quality Assurance• CPC-Center for Drug and Health Plan Choice= Medicare Part C• CERT-Comprehensive Error Rate Testing https://www.cms.gov/cert/• PEPPER-Program for Evaluation Payment Patterns Electronic Report• PERM-Payment Error Rate Measurement (Medicaid/CHIP) http://www1.cms.gov/PERM/

• HEAT-Health Care Fraud Prevention & Enforcement Action Team (LA, Houston and Detroit) http://www.hhs.gov/news/press/2010pres/07/20100716a.html