CMS Pub. 100-04, ch. 28, § 110.2

Inspector General

(Rev. 2906, Issued: 03-14-14, Effective: 04-14-14, Implementation 04-14-14)

The Regional Office should perform preliminary screening activities, which may include

interviewing the complainant in person or by phone (if appropriate), in order to reach a

determination as to referral of the case for further investigation to the Special Agent in

Charge, Office of Investigations, Regional Office of the Inspector General, HHS.

At the point where the RO believes that there exists an indication of the violation of one

of the Federal penalty provisions, the RO should prepare a formal referral to the Regional

OIG. In cases where there is uncertainty as to whether the Federal law has been violated,

the case should be referred notwithstanding the uncertainty. The referral should reflect

the following information:

A. Type of violation, e.g., the complainant alleges a violation of §1882(d)(2);

B. Name, address, and telephone number of the complainant; and

C. A narrative description of the facts, which should include:

1. All circumstances regarding the contact made by the subject with the

beneficiary:

a. Type of contact (phone, personal);

b. Stated reason (if any) for selection of the beneficiary by the subject

making the contact, e.g.:

i. Beneficiary lives in a senior citizens community or

complex;

ii. The existence of another insurance policy with the same

company; and

iii. Referral by a third party.

2. Date, time, place, and duration of all contacts;

3. Words that were used to gain entry into the beneficiary’s home, e.g., “I’m

from Medicare,” “SSA,” or other Federal Government agency;

4. Details of the subject’s sales pitch or presentation:

a. Was there a discussion of the existence of other health insurance

policies currently held by the beneficiary?

b. Did the agent know that his policy was duplicative of Medicare or a

currently held policy?

c. Amount of premium of policy that agent was trying to sell. Obtain a

copy of the policy if possible;

d. Existence of any hard sell or intimidation tactics on the part of the

agent.

5. Details of the Agent’s exit:

a. Business card left by agent; and

b. Follow-up calls by agent or others.

D. Other Information:

1. Name of contact person in the Regional Office;

2. Copy of the original complaint; and

3. Any other supporting documentation.