CMS 101
The law that established the Medicare (Parts A and B) and Medicaid programs
Social Security Amendments of 1965
Conducts program integrity reviews of managed care plans
DMAA
The year AVG was established
2020
An audit that confirms that any diagnoses submitted by an MAO for risk adjustment are supported in the enrollee's medical record
RADV
MLR
Medical Loss Ratio
Name three qualifying events for Medicare eligibility
Conducts oversight of ACOs, and MA and Prescription Drug Plans
DPDA
An audit to confirm if states’ Medicaid and CHIP bene eligibility determinations are appropriate and if Federal match is assessed correctly
Beneficiary Eligibility Audit -or- Unwinding Eligibility Audit
National Correct Coding Initiative
The 2023 Medicare FFS CERT Improper Payment Rate (+/- 1 point)
7.38 percent
Engages leadership and staff across CMS to to identify vulnerabilities in Medicare, Medicaid, and the Marketplace
DVIS
An edit that states the maximum units of service that can be reported for a HCPCS/CPT code by the same provider/supplier for the same beneficiary on the same date of service
Medically Unlikely Edit (MUE)
Hierarchical Condition Category
Number of people who selected a Marketplace plan during the 2024 Marketplace Open Enrollment Period (+/- 5 million)
21.3 million
Participates in the development of CPI- and CMS-wide Medicaid PI strategy, regulations, and policy
DSP
Education that provides training tailored to meet the ongoing needs of state Medicaid employees responsible for protecting the integrity of the Medicaid program
Medicaid Integrity Institute (MII)
PERM CAP
Payment Error Rate Measurement Corrective Action Plan
Total Part D spending, in billions, in 2021 (+/- 25)
$216 billion
Oversees state and Marketplace PI review activities
DSPPI
National contractor that conduct audits, education and outreach and ensures compliance with regulatory requirements
PPI MEDIC
AICE-FWA
Analytics and Investigations Collaborative Environment - Fraud, Waste, and Abuse