CMS Pub. 100-16, ch. 21, § 50.7.4

42 C.F.R. §§ 422.503(b)(4)(vi)(G), 423.504(b)(4)(vi)(G)

Medicare Drug Integrity Contractors (MEDIC) are organizations that CMS contracts with

to perform specific program integrity functions for Parts C and D under the Medicare

Integrity Program. The MEDIC’s primary role is to identify potential fraud and abuse in

Medicare Part C and Part D. There is currently one National Benefit Integrity (NBI)

MEDIC.

NBI MEDICs will investigate referrals from sponsors, develop the investigations, and

make referrals to appropriate law enforcement agencies or other outside entities when

necessary. The NBI MEDIC will keep the sponsor apprised of the development and

status of the investigation. If the NBI MEDIC determines a referral to be a matter related

to noncompliance or mere error rather than fraud or abuse, the matter will be returned to

CMS and/or the sponsor for appropriate follow-up.

Sponsors should refer cases involving potential fraud or abuse that meet any of the

following criteria to the NBI MEDIC:

• Suspected, detected or reported criminal, civil, or administrative law violations;

• Allegations that extend beyond the Parts C and D plans, involving multiple health

plans, multiple states, or widespread schemes;

• Allegations involving known patterns of fraud;

• Pattern of fraud or abuse threatening the life or well being of beneficiaries; and

• Scheme with large financial risk to the Medicare Program or beneficiaries.