Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC)   3

Background
The Centers for Medicare & Medicaid Services (CMS) is seeking to contract with an external entity to support its Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC) work. This initiative focuses on conducting fraud, waste, and abuse (FWA) detection, deterrence, and prevention activities for Medicare Parts C and D.

The goal is to enhance program integrity by collaborating with Medicare Advantage Organizations (MAOs), Medicare Advantage Prescription Drug (MA-PD) plans, and stand-alone Prescription Drug Plan Sponsors (PDPs) through outreach, education, and timely audits to protect the Medicare Trust Fund.

Work Details
The PPI MEDIC will perform a variety of tasks including: conducting data analyses; executing audits and reviews of MAOs and PDPs; providing outreach and education; developing reports such as Peer Activity Reports (PARs); issuing alerts to plan sponsors regarding trends associated with FWA; managing correspondence mailboxes for CMS; overseeing Medicare Prescription Payment processes; conducting improper payment audits including self-audits and national audits; performing program integrity audits; preparing return on investment reports; developing audit protocols; facilitating national FWA training sessions; and maintaining a PI Portal for FWA reporting.

The contractor will also be responsible for coordinating with CMS staff and other stakeholders throughout the audit process.