CMS Pub. 100-08, ch. 3, § 3.7.3.3

This section applies to MACs.

The MACs shall determine if any other corrective actions are necessary

such as:

• Uncovering potential fraud in the course of MR postpayment

review activities. The MR unit shall refer these cases to the UPIC.

If it is believed that the overpayment resulted from potential fraud,

a refund may not be requested from the provider until the potential

fraud issue is resolved.

• Initiating provider or supplier specific edits to focus prepayment

view on the problem provider or supplier or group of providers or

suppliers, if appropriate ;

• Working with the CMS Central Office Division of Benefit Integrity

Management Operations (DBIMO) Fraud and Abuse Suspensions

and Sanctions (FASS) Team to suspend payment to the provider or

group of providers;

• Referring provider certification issues to the State survey agency

through CMS staff;

• Referring quality issues involving inpatient hospital services to the

RO and QIO; and

• Coordinating with the QIO and MAC on interrelated billing

problems

The MACs periodically perform a follow-up analysis of the provider(s) or supplier(s) for

as long as necessary to determine if further corrective actions are required. In some cases,

it may be feasible and timely to perform the follow-up analysis of the provider or supplier

after the three (3) month time period. The MACs shall continue to monitor the

provider(s) or supplier(s) until there is a referral to the UPICs for potential fraud,

evidence that the utilization or billing problem is corrected, or data analysis indicating

resources would be better utilized elsewhere.