Common use of OF THE MATCHING PROGRAM Clause in Contracts

OF THE MATCHING PROGRAM. The purpose of this agreement is to establish the conditions, safeguards, and procedures under which the Centers for Medicare & Medicaid Services (CMS) will conduct a computer matching program with the State of New Jersey, Department of Human Services (NJDHS), Division of Medical Assistance and Health Services (DMAHS) to study claims, billing, and eligibility information to detect suspected instances of Medicare and Medicaid fraud and abuse (F&A) in the State of New Jersey. CMS and NJDHS will provide Electronic Data Systems Corporation, a CMS contractor (hereinafter referred to as the ‘‘Custodian’’), with Medicare and Medicaid records pertaining to eligibility, claims, and billing which the Custodian will match in order to merge the information into a single database. Utilizing fraud detection software, the information will then be used to identify patterns of aberrant practices requiring further investigation. The following are examples of the type of aberrant practices that may constitute F&A by practitioners, providers, and suppliers in the State of New Jersey expected to be identified in this matching program: (1) Billing for provisions of more than 24 hours of services in one day, (2) providing treatment and services in ways more statistically significant than similar practitioner groups, and (3) up-coding and billing for services more expensive than those actually performed.