CMS Pub. 100-08, ch. 4, § 4.5

This section applies to UPICs.

Screening is the initial step in the review of a lead (described in section 4.2.2.1 of this

chapter) to determine the need to perform further investigation based on the potential for

fraud, waste, or abuse. Screening shall be completed within 45 calendar days after

receipt of the lead.

The receipt date of the lead is generally determined by the date the UPIC receives a

complaint. If the lead resulted from data analysis conducted by the UPIC, the receipt of

the lead shall be the date the lead was referred from the UPIC data analysis department

to its investigation or screening unit. For a new lead that is identified from an active or

current UPIC investigation, the receipt of the lead shall be the date the new lead was

identified by the UPIC investigator.

Note: If criteria for an IA are met during evaluation of the lead, the UPIC shall forward

the IA to LE and continue to screen the lead, if deemed appropriate.

Activities that the UPIC may perform in relation to the screening process include, but

are not limited to:

• Verification of provider’s enrollment status;

• Coordination with the MAC on prior activities (i.e., prior medical reviews,

education, appeals information, etc.);

• Data analysis;

• Policy / regulation analysis;

• Contact with the complainant, when the lead source is a complaint;

• Beneficiary interviews; and

• Site verification to validate the provider’s/supplier’s practice location. Note:

While there is no requirement to check locked doors during a site verification,

UPICs are authorized to check the doors. As such, the UPIC shall assess the

environment and use sound judgement to determine when it is appropriate to

check locked doors.

Any screening activities shall not involve contact with the subject provider/supplier or

implementation of any administrative actions (i.e., post-payment reviews, prepayment

reviews/edits, payment suspension, and revocation). However, if the lead is based solely

on a potential assignment violation issue, the UPIC may contact the provider directly to

resolve only the assignment violation issue. If the lead involves potential patient harm,

the UPIC shall immediately notify CMS within two (2) business days.

As it relates to the UPIC’s handling of potential assignment violations, if the UPIC is

unable to make contact with the provider at least five (5) attempts, the UPIC shall refer

the assignment violation issue to the appropriate CMS Regional Office for resolution.

After completing its screening, the UPIC shall close the lead if it does not appear to be

related to fraud, waste, or abuse. Prior to closing the lead, the UPIC shall take any

appropriate actions (i.e., referrals to the MAC, RA, state, or QIO). For example, if a lead

does not appear to be related to potential fraud, waste, or abuse but the lead needs to be

referred to the MAC, the date that the UPIC refers the information to the MAC is the last

day of the screening.

At a minimum, the UPIC shall document the following information in its case file:

• The date the lead was received and closed;

• Lead source (e.g., beneficiary, MAC, provider/supplier);

• Record the name and telephone number of the individual (or organization), if

applicable, that provided the information concerning the alleged fraud or

abuse;

• Indicate the provider's/supplier’s name, address, and ID number;

• Start and end date of the screening;

• Description of the actions/activities performed;

• Start and end date of each action/activity;

• A brief description of the action taken to close the lead (e.g., reviewed records

and substantiated amounts billed). Ensure that sufficient information is

provided to understand the reason for the closeout;

• The number of leads received to date regarding this provider/supplier,

including the present lead. This information is useful in identifying

providers/suppliers that are involved in an undue number of complaints; and

• Any documentation associated with the UPIC’s activities (i.e., referrals to

other entities).

Additionally, if the screening process exceeds 45 calendar days, the UPIC shall

document the reasons, circumstances, dates, and actions associated with the delay in the

UCM and its monthly reporting in CMS ARTS.

If the UPIC identifies specific concerns while screening a lead that warrants contact with

a specific provider/supplier, the UPIC shall contact the BFL, with a copy to the COR, for

further guidance (e.g., UPIC determines that provider/supplier contact is needed in order

to determine if the case warrants further investigation).