The Health Insurance Portability and Accountability Act of 1996 required the establishment of the Incentive Reward Program (IRP). The purpose of the Program is to encourage reports of Medicare fraud. The Federal Department of Health and Human Services, Health Care Financing Administration (HCFA) is responsible for administering the Program. The IRP offers a monetary reward to any individual whose allegations of Medicare fraud result in a minimum recovery of $100 involving individuals or entities that are determined to have committed sanctionable offenses.

Purpose

The purpose of the IRP is to encourage individuals to report information about individuals and/or entities which are or have engaged in acts or omissions that are grounds for sanctioning under a number of provisions of the Social Security Act.

A reward will be given only for information that leads to at least a $100 recovery from individuals or entities determined by HCFA to have committed sanctionable offenses.

The term "sanction" applies, in this context, to any provider, practitioner or supplier and could take the form of:

1. exclusion from Medicare;

2. monetary fines; and/or

3. Criminal penalties.

Information Eligible for a Reward

In order for the information to be considered for a reward, it must:

• relate to a specific situation, individual or entity;
• specify a time period for the alleged activities;
• be relevant and material;
• lead directly to the imposition of a sanction; and
• not already be the subject of an investigation.

Eligibility for a Reward

A reward is payable to all individuals whose complaint(s) lead to a sanctionable offense. When multiple complaints have been received, the following guidelines apply:

• Only complaints directly relevant to the allegation are eligible
• When multiple complaints are of the same nature and concern the same provider, all complainants are eligible to share in equal proportions of the total reward
• The reward should be paid to the complainant(s) who provided sufficient and specific information to open the case.

Not every report of alleged fraud is eligible for a reward. Highmark Medicare Services will make a determination of eligibility as appropriate. It is possible that some cases may be closed without a reward being granted.

Ineligible Individuals

The following are ineligible from the receiving a reward under the Program:

• individuals who are or were employees of HHS, its contractors, SSA, OIG, DOJ and any other federal, state or local law enforcement agency at the time the information came into their possession ( this extends to members of the employee’s immediate family);
• Any employee of any other Federal/state governments, contractors or HHS grantee if the information came to their knowledge during the course of their official duties;
• Any individual who illegally obtained the information; or
• Any individual who participated in the sanctionable offense.

Amount of Rewards

The amount of the rewards will not be more than:

• 10% of the overpayment recovered; or
• $1,000 - whichever is less.

Collected fines and penalties are not included in computing the amount of the reward.

Reward Eligibility Notification

After all fraudulently-obtained Medicare funds have been recovered (and all fines and penalties collected, if appropriate), a reward eligibility notification letter and reward claim form will be sent to the complainant.

Incentive Reward Payment

After the complainant or her legal representative has returned the completed reward claim form with the appropriate attachments, a determination will be made concerning the amount of the reward. The reward will come from money recovered from the overpayment.

As the reward is considered income, a W-2 has to be submitted to the Internal Revenue Service for any reward over the amount of $601.00.  

For more information about the Incentive Reward Program, please contact:

Customer Contact Center
Highmark Medicare Services
120 Fifth Avenue, Suite P5205
Pittsburgh, PA 15222-3099