HI 00208.010 Role of the Centers for Medicare & Medicaid Services (CMS)
CMS is responsible for policy formulation and various operational aspects of the program. These duties are the responsibility of various components.
A. Health Standards and Quality Bureau (HSQB)
Develops, interprets and implements health quality and safety standards and evaluates their impact on the utilization, quality, and cost of health care services;
Develops, interprets, implements, and evaluates the conditions and standards of participation by and monitors and validates certification activities for providers and suppliers of health services under the Medicare and Medicaid programs;
Develops, interprets, implements, and evaluates policies for professional standards review, related peer review, utilization review, and utilization control programs under Medicare and Medicaid;
Develops and manages grants with PSRO’s and contacts with statewide Professional Standards Review Councils and develops policies regarding operational aspects of peer and utilization review programs, including their monitoring and evaluation;
Develops and evaluates health care and health-related policies related to implementation of the End Stage Renal Disease (ESRD) provision and coordinates with Medicare the implementation and monitoring of their policies;
Determines information and data reporting, collection and systems requirements for the PSRO and provider certification programs;
Serves as the CMS focal point in the agency’s interface with the Assistant Secretary for Health and the Public Health Service on Medical Care Standards Quality Assurance, and other health-related matters.
B. Centers for Medicare & Medicaid Services
The Centers for Medicare & Medicaid Services has the primary responsibility for the Health Insurance program. However, nearly every major bureau or office of SSA is involved in some way in carrying out CMS responsibilities.
This responsibility involves the development of policies, guidelines, and procedures used by the intermediaries, carriers, and components of CMS in carrying out their responsibilities for administering the Health Insurance provisions of the Social Security Act.
C. Medicaid Bureau
The Medicaid Bureau has the primary responsibility for administering title XIX of the Social Security Act. As such, it develops and promulgates appropriate policies.
D. Bureau of Quality Control (BQC)
The Bureau of Quality Control has responsibility for insuring the integrity of the Medicare program and investigating all complaints of fraud or abuse against the program. In the furtherance of these objectives, BQC has occasion to work closely with carriers and intermediaries, the CMS regional and central office components, and DO’s among other units.
NOTE: By law and regulation, the Inspector General’s Office of Investigations, (OI), has the responsibility to supervise, coordinate and provide direction for Medicare fraud cases.