TRICARE central coordinating agency that investigates and reviews alleged cases of fraud and abuse committed against the Military Health System (MHS) TRICARE program, its beneficiaries, and U.S. taxpayers. Their active involvement investigating and prosecuting health care fraud cases has resulted in a return of millions of dollars to the federal government and Department of Defense (DoD).

Centers for Medicare and Medicaid Services (CMS) operational account that supplies the agency with the resources to administer Medicare, the federal portion of Medicaid, and other agency responsibilities. The components of Program Management are Medicare contractors, survey and certification, research, and administrative costs.

Automated system of records, primarily those of current Medicare-eligible end-stage renal disease (ESRD) patients. The PMMIS also maintains historical information on people no longer classified as ESRD patients because of death or successful transplantation or recovery of renal function. In addition, it contains information on all dialysis and kidney transplant patients, ESRD facilities, and facility payment. The PMMIS contains medical information on patients and the services that they received during the course of their therapy.

Medicare program day-to-day operating instructions that as of October 1, 2003, are transmitted and incorporated into the applicable Medicare manuals. Archived memorandums are available on the Centers for Medicare and Medicaid Services’ website.

Federal program that combines medical, social, and long-term care services for frail people. It is a provider under Medicare and available only in states that have chosen to offer it under the Medicaid program. An individual’s eligibility requires that he or she be 55 years or older, live in the service area of the PACE program, be certified as eligible for nursing home care by the appropriate state agency, and be able to live safely in the community. PACE’s goal is to help people stay independent and live in their community as long as possible while getting the high-quality care they need.

Contractor hired to investigate an allegation of fraud and establish a case after it is substantiated. Also called contractor. Also see potential fraud case (PSC).

Written notation, dated and signed, by a member of the health care team, that summarizes the facts about the medical care given and the patient’s response during a specific period of time. Also called chart note.

Written or dictated letter or chart note documenting details about subsequent examinations of the patient.

System of giving medically necessary health care at any given stage in illness or recovery (i.e., from acute care in a hospital through the recuperation phase).