Draft Fraud Defense Contracts Statement of Objectives

FRAUD DEFENSE CONTRACTS: STATEMENT OF OBJECTIVES

I. Purpose

The Centers for Medicare & Medicaid Services (CMS) seeks contractor support to protect the integrity of the Medicare program by preventing, detecting, and addressing fraud and abuse. The purpose of this contract is to support CMS by investigating suspected fraud and abuse, protecting CMS programs, and supporting timely, consistent, and defensible administrative, civil, and criminal enforcement actions. The contractor will provide the investigative expertise, clinical and analytical capabilities, management practices, and other support necessary to address evolving fraud schemes and advance CMS’ program integrity priorities.

T

CMS seeks an outcome-focused approach that promotes timely and consistent action, effective coordination with Federal, State, and private program integrity partners, appropriate use of data and technology, and meaningful results in the prevention, detection, and disruption of fraud.

AF

CMS will establish program integrity priorities, assign and prioritize investigations, and retain authority over Government decisions and actions requiring CMS approval. Within those parameters, the contractor shall be responsible for planning, managing, and executing the investigative activities necessary to develop assigned matters efficiently and to support appropriate program integrity and enforcement outcomes.

R

Offerors shall propose the approach, staffing, tools, quality controls, performance measures, and management practices necessary to perform the work described in this Statement of Objectives.
II. Scope or Mission

D

The contractor shall provide program integrity support within its assigned jurisdiction by: •
•

•

•
•

Receiving and working CMS-assigned fraud investigations in accordance with CMSestablished priorities. Conducting the CMS directed investigative activities, including claims and other authorized data analysis, targeted pre-payment and/or post-payment medical review, onsite or boots-on-the-ground activities, provider/supplier/beneficiary interviews and retrieval of attestations, document and evidence collection, and other appropriate investigative actions directed by CMS.
Identifying, developing, recommending, and supporting appropriate administrative actions, including payment suspensions, revocations, and other available program integrity remedies, subject to applicable CMS approval and direction. Developing and supporting law enforcement referrals and other criminal, civil, and