US · guidance
CMS Pub. 100-08, ch. 4, § 4.9.4.1
Referral to State Agencies or Other Organizations
The UPIC shall refer instances of apparent unethical or improper practices or
unprofessional conduct to state licensing authorities, medical boards, the QIO, or
professional societies for review and possible disciplinary action.
Additionally, referrals should be made to the Medicare survey and certification agency
which exist in each state, typically within the state’s Department of Health. The survey
agency has a contract with CMS to survey and certify institutional providers, indicating
whether they meet or do not meet applicable Medicare health and safety requirements,
called “conditions of participation.” Providers not meeting these requirements are
subject to a variety of adverse actions, including bans on new admissions to termination
of their provider agreements. These administrative sanctions are imposed by the
Regional Office, typically after an onsite survey by the survey agency.
The UPIC’s and the MAC’s MR staffs shall confer before such referrals, to avoid
duplicate referrals. The UPIC shall gather available information and leave any further
investigation, review, and disciplinary action to the appropriate professional society or
State board. Consultation and agreement between the UPIC’s and the MAC’s MR staffs
shall precede any referral to these agencies.
The UPIC shall notify its BFL, with a copy to the COR, of these referrals.
History
(Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
1040d47ac6ac48e33df65c61e716175b94271d1d0814316b62fde53e0ceb4eca
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