CMS Pub. 100-08, ch. 4, § 4.9.2

The UPIC shall identify cases of potential fraud and shall make referrals of such cases,

as appropriate, to the OIG/OI, regardless of dollar thresholds or subject matter. Matters

shall be referred when the UPIC has documented allegations including, but not limited

to, a provider, beneficiary, supplier, or other subject, a) engaged in a pattern of improper

billing, b) submitted improper claims with suspected knowledge of their falsity or c)

submitted improper claims with reckless disregard or deliberate ignorance of their truth

or falsity.

If the UPIC believes a case should be referred to LE, the UPIC shall discuss the matter

with its BFL. If the BFL agrees that referral to LE is appropriate, the UPIC shall update

the UCM appropriately to ensure the provider/supplier is included in the next case

coordination meeting discussion for final approval. If it is determined an investigation

should be referred to LE, the UPIC shall refer the matter to the designated OIG/OI

Special Agents-in-Charge (SAC), Department of Justice Assistant United States Trial

Attorneys, or other parties identified during the case coordination discussion. In such

instances, the UPIC shall make immediate referrals to the designated parties within

seven (7) calendar days, unless otherwise specified by its BFL.

Referrals to LE shall include all applicable information that the UPIC has obtained

through its investigation at the time of the referral. The UPIC shall utilize the “LE

Referral Template” available in PIM Exhibit 16.1 Additionally, if the referral is related

to a multi-jurisdiction or national provider/supplier, the UPIC shall coordinate and

collect all applicable investigative information from the other UPICs that have an open

investigation on that same provider/supplier. The UPIC shall then send one

comprehensive referral with all the UPICs’ investigative findings to LE. Once the

referral package is complete, the UPIC shall submit the referral to LE and copy its COR

and BFL. Upon submission of the referral to LE, the UPIC shall request written and/or

email confirmation from LE acknowledging receipt of the referral. UCM shall be

updated with the date the referral was sent, the name of the agent acknowledging receipt

of the referral, and the date of receipt. In the event that written confirmation is not

received, the UPIC shall notify the appropriate BFL, with a copy to the COR.

As previously instructed, the UPIC shall continue to refrain from implementing any

additional administrative actions against the provider/supplier without CMS approval

during the 60-day window OIG/OI and/or DOJ has to respond to the referral.

If OIG/OI and/or DOJ declines the case, the UPIC shall notify its COR and respective

CPI points of contact within two (2) business days in order to move forward with the

secondary administrative actions identified during the case coordination meeting.

Following this notice, the UPIC shall work with its respective BFL or suspension team

member on developing the appropriate documentation for the designated secondary

actions.

Regarding LE Referrals that are declined and/or returned to the I-MEDIC to take

appropriate administrative action to the extent possible, should there be an outstanding

overpayment that the Medicare Part C Plan Sponsor(s) could develop, upon receipt of

LE’s Referral declination/return, the I-MEDIC shall notify the appropriate Medicare Part

C Plan Sponsor(s) of the status of the LE Referral and the outstanding overpayment, and

advise the Medicare Part C Plan Sponsor(s) to move forward with the overpayment

recovery efforts.

This notification shall take place within five (5) business days upon receipt of the

declination/return of the LE Referral. In addition, the I-MEDIC shall document this

communication in the UCM REF record, indicating the date of the LE Referral

declination/return, outstanding overpayment amount, if appropriate. The I-MEDIC shall

also document the Medicare Part C Plan Sponsors impacted, the date the notification

was issued to the Medicare Part C Plan Sponsors, as well as the point-of-contact at the

Medicare Part C Plan Sponsor(s) who received the notification. Upon submission of this

notification to the Medicare Part C Plan Sponsor(s), the I-MEDIC shall close the REF

record as required.