CMS Pub. 100-08, ch. 4, § 4.2.2.6

This section applies to UPICs and MACs, as indicated.

The MAC personnel conducting each segment of claims adjudication, MR, and

professional relations functions shall be aware of their responsibility for identifying

potential fraud, waste, or abuse and be familiar with internal procedures for forwarding

potential fraud, waste, or abuse instances to the UPIC. Any area within the MAC (e.g.,

MR, enrollment, screening staff) that refers potential fraud, waste, and abuse to the

UPIC shall maintain a log of all these referrals. At a minimum, the log shall include the

following information: provider/physician/supplier name, beneficiary name, Health

Insurance Claim Number (HICN), nature of the referral, date the referral is forwarded to

the UPIC, name and contact information of the individual who made the referral, and the

name of the UPIC to which the referral was made.

The MAC shall provide written procedures for personnel in various contractor functions

(claims processing, MR, beneficiary services, POE, cost report audit, etc.) to help

identify potential fraud situations. The MAC shall include provisions to ensure that

personnel shall:

• Refer potential fraud, waste, or abuse situations promptly to the UPIC;

• Forward complaints alleging fraud through the screening staff to the UPIC;

• Maintain confidentiality of referrals to the UPIC;

• Forward to the UPIC detailed documentation of telephone or personal contacts

involving fraud issues discussed with providers/suppliers or provider/supplier

staff, and retain such information in individual provider/supplier files; and

The UPIC shall ensure the performance of the functions below and have written

procedures for implementing these functions:

Investigations:

• Keep educational/warning correspondence with providers/suppliers and other

fraud documentation concerning specific issues in individual provider/supplier

files so that the UPICs are able to easily retrieve such documentation;

• Maintain documentation on the number of investigations alleging fraud, waste

or abuse, the number of cases referred to the OIG/OI (and the disposition of

those cases), processing time of investigations, and types of violations referred

to the OIG (e.g., item or service not received, unbundling, waiver of co-payment) and;

• Conduct investigations (following a plan of action) and make the appropriate

beneficiary and provider contacts.

Communications/Coordination:

• Maintain communication and information flowing between the UPIC and the

MAC MR staff, and as appropriate, MAC audit staff;

• Communicate with the MAC MR staff on all findings of overutilization and

coordinate with the MAC POE staff to determine what, if any, education has

been provided before any PI investigation is pursued;

• Obtain and share information on health care fraud issues/fraud investigations

among MACs, UPICs, CMS, and LE;

• Coordinate, attend, and actively participate in fraud-related

meetings/conferences and inform, as well as, include all appropriate parties in

these meetings/conferences. These meetings/conferences include, but are not

limited to, health care fraud task force meetings, conference calls, and

industry- specific events;

• Distribute Fraud Alerts released by CMS to their staff;

• Serve as a resource to CMS, as necessary; for example, serve as a resource to

CMS on the UCM, provide ideas and feedback on Fraud Alerts and/or

vulnerabilities within the Medicare or Medicaid programs;

• Report to the BFL, with a copy to the COR all situations that have been

identified in which a provider consistently fails to comply with the provisions

of the assignment agreement; and

• Coordinate and communicate with the MR units within the MACs to avoid

duplication of work.

Coordination with Law Enforcement:

• Serve as a reference point for LE and other organizations and agencies to

contact when they need help or information on Medicare fraud issues and do

not know whom to contact;

• Hire and retain employees who are qualified to testify in a criminal and civil

trial when requested by LE;

• Provide support to LE agencies for investigation of potential fraud, including

those for which an initial referral to LE did not originate from the UPIC;

• Meet (in person or via telephone call) with OIG agents to discuss pending or

potential cases, as necessary;

• Meet (in person or via telephone) when needed with the DOJ to enhance

coordination on current or pending cases;

• Furnish all available information upon request to the OIG/OI with respect to

excluded providers/suppliers requesting reinstatement;

• Notify, via e-mail, the BFL, with a copy to the COR, who will obtain approval

or disapproval when the UPIC is asked to accompany the OIG/OI or any other

LE agency onsite to a provider/supplier for the purpose of gathering evidence

in a potential fraud case (e.g., executing a search warrant). However, LE must

make clear the role of UPIC personnel in the proposed onsite visit. The

potential harm to the case and the safety of UPIC personnel shall be

thoroughly evaluated. The UPIC personnel shall properly identify themselves

as UPIC employees and under no circumstances shall they represent

themselves as LE personnel or special agents. Lastly, under no circumstances

shall UPIC personnel accompany LE in situations in which their personal

safety is in question; and

• Maintain independence from LE and do not collect evidence, i.e., request

medical records or conduct interviews, at LE’s request. The UPIC is expected

to follow the current vetting process and the requirements of PIM Section 4.6.

Training:

• Work with the BFL, with a copy to the COR, to develop and organize external

programs and perform training, as appropriate, for LE, ombudsmen, grantees

(e.g., Senior Medicare Patrols), and other CMS health care partners (e.g.,

Administration on Aging, state MFCUs);

• Help to develop fraud-related outreach materials (e.g., pamphlets, brochures,

videos) in cooperation with beneficiary services and/or provider relations

department of the MACs for use in their training. Prior to submission to the

requesting party, the UPIC shall submit the written outreach material to the

BFL, with a copy to the COR, for clearance;

• Assist in preparing and developing fraud-related articles for MAC

newsletters/bulletins. Once completed but prior to submission to the requesting

party, the UPIC shall submit such materials to the BFL, with a copy to the

COR, for clearance; and

• Provide resources and training for the development of existing employees and

new hires.

The MACs shall ensure the performance of the functions below and have written

procedures for these functions:

• Ensure no payments are made for items or services ordered, referred, or

furnished by an individual or entity following the effective date of exclusion

(refer to § 4.10, for exceptions);

• Ensure all instances in which an excluded individual or entity that submits

claims for which payment may not be made after the effective date of the

exclusion are reported to the OIG (refer to PIM, Chapter 8); and

• Ensure no payments are made to a Medicare provider/supplier that employs an

excluded individual or entity.