CMS Pub. 100-15, ch. 1, § 1.1

A. Provisions for the Work of the Unified Program Integrity Contractors

Section 1936 of the Social Security Act (the Act), established by the Deficit Reduction

Act of 2005, is the statutory authority under which the Unified Program Integrity

Contractors (UPICs) operate their Medicaid functions.

Section 1936(a) of the Act provides that the Secretary must enter into contracts with

eligible entities to conduct certain activities specified at section 1936(b) of the Act.

Section 1936(b) of the Act provides that eligible entities under contract with the Centers

for Medicare & Medicaid Services (CMS) will provide the following activities:

(1) Review the actions of individuals or entities furnishing items or services

(whether fee-for-service, risk, or other basis) under a State plan or any waiver to

determine whether fraud, waste, or abuse has occurred; is likely to occur; or whether such

actions have any potential for resulting in an expenditure of funds which is not intended.

(2) Audit of claims for payment for items or services furnished, or administrative

services rendered, under a State plan, including (A) cost reports; (B) consulting contracts;

and (C) risk contracts under section 1903(m).

(3) Identification of overpayments to individuals or entities receiving federal

funds under this title.

(4) Education or training, as the Secretary may establish, of certain individuals

and entities with respect to payment integrity and quality of care.

Additionally, Section 6402 of the Patient Protection and Affordable Care Act (Affordable

Care Act) provides guidance related to the Medicaid integrity program; health care fraud

oversight and guidance; suspension of Medicaid payments pending investigation of

credible allegations of fraud; and the increased funding associated with targeting and

preventing Medicaid fraud, waste, and abuse.

Lastly, Section 6506 of the Affordable Care Act provides guidance related to Medicaid

overpayment recoupment and federal repayment.

B. Provisions for State Collaboration with the Unified Program Integrity

Contractors

Section 1902(a)(69) of the Act entitled, “State Requirement to Cooperate with Medicaid

Integrity Program Efforts” requires that the Medicaid State plan “provide that the State

must comply with any requirements determined by the Secretary to be necessary for

carrying out the Medicaid Integrity Program established under section 1936.”

C. Provisions for the Medicare-Medicaid Data Match Program (Medi-Medi

Program)

Section 1893(g) of the Act established the Medicare-Medicaid Data Match Program,

which stipulated that:

(1) Expansion of program.—

(A) In general.—The Secretary shall enter into contracts with eligible entities or

otherwise for the purpose of ensuring that, beginning with 2006, the Medicare-Medicaid

Data Match Program (commonly referred to as the “Medi-Medi Program”) is conducted

with respect to the program established under this title and State Medicaid programs

under title XIX for the purpose of—

(i) identifying program vulnerabilities in the program established under

this title and the Medicaid program established under title XIX through the use of

computer algorithms to review claims data to look for payment anomalies

(including billing or billing patterns identified with respect to provider, service,

time, or patient that appear to be suspect or otherwise implausible);

(ii) working with States, the Attorney General, and the Inspector General

of the Department of Health and Human Services to coordinate appropriate

actions to investigate and recover amounts with respect to suspect claims to

protect the Federal and State share of expenditures under the Medicaid program

under title XIX, as well as the program established under this title;

(iii) increasing the effectiveness and efficiency of both such programs

through cost avoidance, savings, and recoupments of fraudulent, wasteful, or

abusive expenditures; and

(iv) furthering the Secretary’s design, development, installation, or

enhancement of an automated data system architecture—

(I) to collect, integrate, and assess data for purposes of program

integrity, program oversight, and administration, including the Medi-Medi

Program; and

(II) that improves the coordination of requests for data from States.

(B) Reporting requirements.—The Secretary shall make available in a timely

manner any data and statistical information collected by the Medi-Medi Program to the

Attorney General, the Director of the Federal Bureau of Investigation, the Inspector

General of the Department of Health and Human Services, and the States (including a

Medicaid fraud and abuse control unit described in section 1903(q)). Such information

shall be disseminated no less frequently than quarterly.

(2) Limited waiver authority. The Secretary shall waive only such requirements of this

section and of titles XI and XIX as are necessary to carry out paragraph (1).

(3) Incentives for states. The Secretary shall study and, as appropriate, may specify

incentives for States to work with the Secretary for the purposes described in paragraph

(1)(A)(ii). The application of the previous sentence may include use of the waiver

authority described in paragraph (2).